LIBRARY 

OF  THE 

UNIVERSITY  OF  CALIFORNIA. 


GIFT  OF" 


«   0  . 


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• 


TREASURY   DEPARTMENT. 
Public  Health  and  Marine-Hospital  Service  of  the  United  States. 


HANDBOOK 


FOR  THE 


SHIP'S  MEDICINE  CHEST, 


BY 


GEORGE  W.  STONER,  M.  D., 

Surgeon,  U.  S.  Public  Health  and  Marine-Hospital  Service. 


PREPARED    BY  DIRECTION 

OK   THK 

SURGEON-GENERAL. 


SECOND   EDITION. 


o 
UNiV;-r.3ITY 


'ON: 

GOVERNMENT    PRINTING   OFFICE, 
1904. 


SURGEON-GENERAL, 

•'"•MBMMW^- 

U.  S.  PUBLIC  HEALTH  AXD  MARINE-HOSPITAL  SEKVICE.. 
Document  No.  2389. 


CONTENTS. 


Page. 

The  medicine  chest .' _ _  7 

1.  Surgical  instruments . . 7 

2.  Miscellaneous  articles 7 

3.  Drugs  and  medicines . . .  8 

4.  Pills 8 

5.  Compressed  tablets ..  8 

6.  Hard-filled  capsules  . .  8 

7.  Tablet  triturates  . .  8 

8.  Lozenges 8 

9.  Essences,  elixirs,  tinctures,  etc 9 

Important  measures  to  be  observed  by  the  captain  of  the  ship_ .  9 

Requirements  at  sea  . .  9 

Yellow  fever  . 11 

Malarial  fever  . . .  16 

Smallpox . .  21 

Cholera,  epidemic,  Asiatic  _, : 24 

The  plague  . .  26 

Beriberi 29 

Dysentery j 32 

Sunstroke 34 

Diarrhea ...  35 

Cholera  morbus  .  _  _  36 

Colic 37 

Scurvy 38 

Sore  throat  - .  39 

Erysipelas 40 

Rheumatism 41 

Delirium  tremens--  44 

Syphilis 45 

Soft  chancre  (chancroids) 46 

Gonorrhea  - 48 

Stricture  urethra 50 

Itch 52 

Boils  _ .  52 

Piles 53 

Injuries— Hemorrhage  (bleeding) 53 

Wounds .     54 

Burns  and  scalds 56 

Effects  of  cold  (frostbite)  . . .  57 

Scalp  wounds 58 

Wounds  of  the  face . 58 

3 

129097 


Injuries  to  the  chest 58 

Injuries  to  the  back 59 

Broken  bones  (fractures) 59 

Fracture  of  the  lower  jaw 60 

Fracture  of  the  thumb  and  fingers  .  62 

Fracture  of  the  forearm 62 

Fracture  of  the  arm  (between  the  elbow  and  shoulder) 63 

Fracture  of  the  thigh  _•  _  65 

Fracture  of  the  kneecap 69 

Fracture  of  the  leg  (below  the  knee)  . .  70 

Compound  fractures 72 

Dislocations 73 

Dislocation  of  the  fingers  _       74 

Dislocation  of  the  thumb  .                   74 

Dislocation  of  the  wrist 75 

Dislocation  of  the  elbow 75 

Dislocation  of  the  shoulder 77 

Dislocation  of  the  collar  bone 78 

Dislocation  of  the  toes 78 

Dislocation  of  the  ankle 78 

Dislocation  of  the  knee.   .  79 

Dislocation  of  the  hip  .  79 

Sprains 81 

Nosebleed 81 

Drowning: 

Directions  for  restoring  the  apparently  drowned 82 

Instructions  for  saving  drowning  persons  by  swimming  to  their  relief  -  87 

APPENDIX. 

The  U.  S.  Public  Health  and  Marine-Hospital  Service. .  89 

Relief  stations 89 

Beneficiaries 90 

Hospital  relief 91 

Out-patient  relief 91 

The  Revenue-Cutter  Service  .  91 

The  Mississippi  River  Commission 92 

The  Engineer  Corps,  U.  S.  Army. .  92 

The  Life-Saving  Service  - .  92 

The  Light-House  Service.                                                 93 

U.  S.  Army  and  Navy  _  93 

Foreign  seamen -  - 93 

Index  .  95 


U.  S.  PUBLIC  HEALTH  AND  MARINE-HOSPITAL  SERVICE, 

NEW  YORK,  N.  Y.  (IMMIGRATION  DEPOT), 

September  16,  1904. 
To  the  SURGEON-GENERAL, 

Public  Health  and  Marine-Hospital  Service, 

Washington,  D.  0. 

SIR:  In  compliance  with  your  directions,  I  have  prepared  and  beg 
leave  to  submit  herewith  a  second  edition  of  the  Handbook  for  the 
Ship's  Medicine  Chest. 

The  article  on  yellow  fever  has  been  revised,  new  articles  on  the 
plague  and  on  beriberi  have  been  added,  an  extract  from  the  United 
States  Quarantine  Regulations  has  been  inserted,  and  the  order  of 
subjects  of  the  handbook  has  been  rearranged. 
Respectfully  submitted. 

GEO.  W.  STONER, 
Surgeon,  Public  Health  and  Marine-Hospital  Service. 


HANDBOOK  FOR  THE  SHIP'S  MEDICINE  CHEST. 


THE  MEDICINE  CHEST. 


SURGICAL   INSTRUMENTS. 


Catheters,  rubber,  assorted  sizes,  G. 

Catheters,  soft  rubber,  assorted  sizes,  6. 

Catheters,  silver,  2. 

Forceps,  artery,  4. 

Forceps,  dissecting,  2. 

Forceps,  dressing,  2. 

Knife,  bistoury,  straight,  blunt  point,  1. 

Knife,  bistoury,  curved,  sharp  point,  1. 

Knife,  bistoury,  straight,  blunt   point,  1. 

Knives,  sea  pel,  2. 

Needles,  surgeon's,  st might  and  curved, 

assorted  sizes,  12. 

Pins,  safety,  assorted  sizes,  boxes,  4. 
Probes,  silver,  2. 


Scissors,  straight,  sharp-pointed,  1. 
Scissors,  straight,  blunt-pointed,  1. 
Scissors,  curved,  blunt-pointed,  1. 
Suturing  materials : 
Catgut,   aseptic,   assorted   sizes,   pa- 
pers, 12. 

Silk,  assorted  sizes,  spools,  4. 
Silkworm  gut,  box,  1. 
Silver  wire,  30  gm. 
(The  silk  and  catgut  are  also  used 
MS   ligatures   for  tying  blood  ves- 
sels. ) 

Tongue  depressor,  1. 
Trocar  and  cannula,  curved,  1. 


MISCELLANEOUS    ARTICLES. 


Adhesive  plaster. 

Absorbent  cotton. 

Bandage,  Esmarch's,  1. 

Bandages,  flannel,  assorted  sizes,  12. 

Bandages,  muslin,  roller,  assorted  sizes, 

48. 

Bandages,  rubber,  2. 
Bedpan,  1. 

Binder's  board,  sheets,  6. 
Droppers,  medicine,  G. 
Feeding  cups,  2. 
Flannel,  10  yards. 
Footbath,  1. 
Fracture  box,  1. 
Gauze,  plain,  aseptic,  10  yards. 
Gauze,  bichloride,  5  yards. 
Gauze,  iodoform,  5  yards. 
Glasses,  graduate,  2. 
Glasses,  medicine,  4. 


Hot-water  bags,  2. 

Ice  bags,  or  ice  caps,  2. 

Lint,  5  yards. 

Muslin,  20  yards. 

Oiled  muslin,  5  yards. 

Oiled  silk,  5  yards. 

Rubber  sheets,  2. 

Rubber  tissue,  5  yards. 

Rubber  tubing,  assorted  sizes,  10  yard 

Sand  bags,  4. 

Splint,- double  inclined  plane,  1. 

Splints,  molded,  set,  1. 

Suspensory  bandages,  12. 

Syringes,  Davidson's,  2. 

Syringe,  fountain,  1. 

Syringes,  glass,  12. 

Urinals,  glass,  2. 

Weight  and  pulley,  1. 


DRUGS    AND    MEDICINES. 


Acid,  carbolic. 

Acid,  nitric. 

Argonin. 

Beef  extract. 

Bismuth,  subcarbonate. 

Black  wash. 

Borax. 

Blotting  paper. 

Calomel. 

Carbolic  soap. 

Castor  oil. 

Collodion. 

Epsom  salts. 

Ipecac  powdered. 

Linseed  (flaxseed),  ground. 

Glycerin. 


Linseed  oil. 
lodoform. 
Mustard. 
Olive  oil. 

Potassium  citrate. 
Rochelle  salts. 
Seidlitz  powders. 
Sulphur  ointment. 
Sulphur,  roll. 
Vaseline. 
Vichy  salts. 
Zinc  acetate. 
Zinc  oxide. 
Zinc-oxide  ointment. 
Zinc  sulphate. 


PILLS. 


Anti-constipation. 
Blue  mass,  5  grains  (0.33  gm.). 
Calomel,  2  grains (0.13  gin.). 
Calomel,  5  grains  (0.33  gm.). 
Camphor   and  opium,   2   grains    (0.12 

gm.)    camphor,   1   grain    (0.06  gm.) 

opium. 

Cathartic,  compound,  U.  S.  P. 
Copaiba  mass,  3  grains  (0.20  gm.). 
Mercurous  iodide,  i  grain  (0.010  gm.). 


Morphine  sulphate,^  grain  (0.01  gm.). 

Opium,  U.  S.  P.,  1  grain  (0.06  gm.). 

Opium  and  lead  acetate,  i  grain  (0.03 
gm.)  opium,  14  grain  (0.10  gm.) 
lead  acetate. 

Quinine,  iron,  and  strychnine  phos- 
phate. 

Quinine  sulphate,  2  grains  (0.13  gm.). 

Quinine  sulphate,  5  grains  (0.33  gm.). 


COMPRESSED    TABLETS. 


Brown  mixture  and  ammonium  chlo- 
ride. 

Calomel  and  sodium  bicarbonate,  1 
grain  (0.065  gm.)  calomel,  1  grain 
(0.065  gm.)  sodium  bicarbonate. 

Cathartic,  vegetable. 

Cocaine. 

Cough. 

Diarrhea. 

Dover's  powder,  5  grains  (0.33  gm.). 


Gargle 

Nausea. 

Phenacetine,  5  grains  (0.33  gm.). 

Potassium  bromide,  10  grains  (0.66 
gm. ) . 

Potassium  chlorate  and  borax,  2* 
grains  (0.16  gm.)  potassium  chlo- 
rate, 2£  grains  (0.16  gm.)  borax. 

Potassium  iodide,  5  grains  (0.33  gm.). 


HARD-FILLED    CAPSULES. 

Copaiba,  10  drops.  Santal  oil,  10  drops. 

Copaiba  and  santal   (5  drops  copaiba,     Santal  oil,  5  drops. 
5  drops  santal). 

TABLET   TRITURATES. 

Aconite,  tincture,  1  drop.  Morphine  sulphate,  f  grain  (0.01  gm.). 

Mercurous  iodide,  %  grain   (0.03  gm.).     Opium  powder,  £  grain  (0.03  gm.). 

LOZENGES. 

Potassium    chlorate,    2    grains    (0.13     Potassium    chlorate    and    ammonium 
gm. ) .  chloride. 


ESSENCES,    ELIXIRS,    TINCTURES,    ETC. 

Essence  of  peppermint  Tincture  of  capsicum. 

Elixir,  aromatic.  Tincture  of  chloride  of  iron. 

Elixir  of  calisaya.  Tincture  of  ginger. 

Elixir     calisaya,    iron,     quinine,  and     Tincture  of  iodine. 

strychnia.  Tincture  of  kino. 

Paregoric.  Tincture  of  myrrh. 

Sirup,  hypophosphites  with  iron.  Tincture  of  opium  (laudanum.). 

Tincture  of  arnica.  Turpentine. 
Tincture  of  benzoin. 

LIQUORS. 

Brandy.  rimmpagne. 

Whisky. 

MIXTURES. 

Hot  drops.  Balsam  copaiha  mixture. 

Sun  cholera  mixture.  Lead  and  opium  wash. 

IMPORTANT  MEASURES  TO  BE  OBSERVED  BY  THE  CAPTAIN  OF  THE  SHIP. 

The  following  is  an  extract  from  the  Quarantine  Regulations, 
issued  by  the  Secretary  of  the  Treasury  upon  the  recommendation 
of  the  Surgeon-General  of  the  Public  Health  and  Marine-Hospital 
Service  of  the  United  States : 

REQUIREMENTS    AT    SEA. 

The  master  of  a  vessel  should  observe  the  following  measures  on 
board  his  vessel : 

(a)  The  water-closets,  forecastle,  bilges,  and  similar  portions  of 
the  vessel  liable  to  harbor  infection  should  be  disinfected  and  fre- 
quently cleansed. 

(fr)  Free  ventilation  and  rigorous  cleanliness  should  be  maintained 
in  all  portions  of  the  ship  during  the  voyage  and  measures  taken  to 
destroy  rats,  mice,  fleas,  flies,  roaches,  mosquitoes,  and  other  vermin. 

(c)  A  patient  sick  of  a  communicable  disease  should  be  isolated 
and  one  member  of  the  crew  detailed  for  his  care  and  comfort,  who, 
if  practicable,  should  be  immune  to  the  disease. 

(d)  Communication  between  the  patient  or  his  nurse  and  other 
persons  on  board  should  be  reduced  to  a  minimum. 

(e)  Used  clothing,  body  linen,  and  bedding  of  the  patient  and 
nurse  should  be  immersed  at  once  in  boiling  water  or  in  a  disinfecting 
solution. 

(/)  The  compartment  from  which  the  patient  was  removed  should 
be  disinfected  and  thoroughly  cleansed.  Articles  liable  to  convey 
infection  should  remain  in  the  compartments  during  the  disinfection 
when  gaseous  disinfection  is  used. 

(g)  Any  person  suffering  from  malaria  or  yellow  fever  should  be 


10 

kept  under  mosquito  bars  and  the  apartment  in  which  he  is  confined 
closely  screened  with  mosquito  netting.  All  mosquitoes  on  board 
should  be  destroyed  by  burning  Pyrethrum  powder  (Persian  insect 
powder)  or  by  fumigation  with  sulphur.  Mosquito  larvae  (wigglers 
or  wiggle  tails)  should  be  destroyed  in  water  barrels,  casks,  and  other 
collections  of  water  about  the  vessel  by  the  use  of  petroleum  (kero- 
sene). Where  this  is  not  practicable,  use  mosquito  netting  to  prevent 
the  exit  of  mosquitoes  from  such  breeding  places. 

(h)  In  the  case  of  plague  special  measures  must  be  taken  to  de- 
stroy rats,  mice,  fleas,  flies,  ants,  and  other  vermin  on  board. 

(i)  In  the  case  of  cholera,  typhoid  feA^er,  or  dysentery  the  drink- 
ing water  should  be  boiled  and  the  food  thoroughly  cooked.  The 
discharges  from  the  patient  should  be  immediately  disinfected  and 
thrown  overboard. 

An  inspection  of  the  vessel,  including  the  steerage,  should  be  made 
by  the  ship's  physician  once  each  day. 

Should  cholera,  yellow  fever,  smallpox,  typhus  fever,  plague,  or 
any  other  communicable  disease  appear  on  board  a  ship  while  at  sea, 
those  who  show  symptoms  of  these  diseases  should  be  immediately 
isolated  in  a  proper  place.  The  ship's  physician  should  then  immedi- 
ately notify  the  captain,  who  should  note  same  in  his  log,  and  all 
of  the  effects  liable  to  convey  infection  which  have  been  exposed  to 
infection  should  be  destroyed  or  disinfected. 

The  hospital  should  be  disinfected  as  soon  as  it  becomes  vacant. 

The  dead  should  be  enveloped  in  a  sheet  saturated  with  one  of  the 
strong  disinfecting  solutions,  without  previous  washing  of  the  body, 
and  at  once  buried  at  sea  or  placed  in  a  coffin  hermetically  sealed. 

A  complete  clinical  record  should  be  kept  by  the  ship's  surgeon  of 
allcases  of  sickness  on  board  and  the  record  delivered  to  the  quaran- 
tine officer  at  the  port  of  arrival. 

The  following  disinfecting  solutions  are  recommended  for  use 
at  sea : 

Formulae  for  slront/  flixiitfc<iin</  solutions. 

Bichloride  of  mercury  (1 :  500)  :  Parts. 

Bichloride  of  mercury 1 

Sea   water 500 

Mix. 
Carbolic  acid  (5  per  cent)  : 

Alcohol    50 

Carbolic  acid,  pure 50 

Mix. 

Then  add  fresh  water 900 

Formula'  for  weak  solutions. 

Bichloride  of  mercury  (1 : 1,000)  : 

Bichloride  of  mercury 1 

Sea   water..  .  1,000 


11 

Carbolic  acid  (2.5  per  cent)  : 

Carbolic  acid,  pure 25 

Fresh   water 1,  000 

Formalin  (5  per  cent)  : 

Formalin   (or  formol) 50 

Water 950 

It  is  suggested  that  a  vessel  should  carry  for  every  100  passengers 
bichloride  of  mercury,  5  pounds;  carbolic  acid,  10  pounds;  alcohol, 
10  pounds,  and  formalin,  10  pounds. 

YELLOW    FEVER. 

Yellow  fever  is  an  acute  infectious  disease  of  the  Tropics,  charac- 
terized by  a  febrile  paroxysm,  yellowness  of  the  skin  or  conjunctiva 
(jaundice),  albuminuria,  suppression  of  urine,  and  bloody  or  black 
vomit.  It  is  transmitted  from  one  person  to  another  through  the  bite 
of  a  species  of  mosquito,  the  Stegomyia  faciata. 

The  disease  is  endemic  in  the  West  Indies,  on  the  Mexican  coast 
of  the  Gulf,  in  Central  America,  on  the  coast  of  Brazil,  and  West 
coast  of  Africa.  It  has  frequently  been  carried  to  southern  ports 
and  to  different  places  in  the  South  Atlantic  and  Gulf  States  of  this 
country,  and  occasionally  to  certain  ports  in  Europe ;  but  it  has  never 
gained  a  firm  foothold  in  the  old  country  except  on  the  west  coast  of 
Africa,  and  is  unknown  in  the  Orient. 

"  Yellow  fever  is  not  endemic  in  Europe,  nor  does  it  naturally  pre- 
vail anywhere  in.  North  America,  yet  it  may  be  carried  almost  any- 
where. Imported  epidemics  have  occurred  at  ports  of  England, 
France,  Spain,  and  Portugal,  and  nearly  all  of  the  ports  on  the  Atlan- 
tic seaboard  of  the  United  States."  (Wyman.) 

The  specific  cause  or  germ  of  yellow  fever  has  not  yet  been  deter- 
mined, but  the  disease  is  communicated  from  one  person  to  another 
through  the  bite  of  a  species  of  mosquito,  the  Stegomyia  faciata. 

For  the  proof  of  this  statement  it  is  only  necessary  to  refer  to  the 
conclusion  of  the  United  States  Army  yellow- fever  commission 
of  1900-1901  (Doctors  Reed,  Carroll,  Lazear,  and  Agramonte)  as 
reported  by  the  head  of  said  commission,  the  late  Walter  Reed, 
major  and  surgeon,  U.  S.  Army.  To  the  brilliant  work  of  this  com- 
mission we  are  indebted  for  the  demonstration  of  the  fact,  previously 
suggested  by  Doctor  Finlay,  of  Habana,  that— 

The  mosquito  (Stegomyia  faciata)  serves  as  the  intermediate  host  of  the  para- 
site of  yellow  fever. 

Yellow  fever  is  transmitted  to  the  iiouimmnne  individual  by  means  of  the  bite 
of  a  mosquito  that  has  fed  previously  on  the  blood  of  those  sick  with  this 
disease. 

Yellow  fever  is  not  conveyed  by  fomites,  and  hence  disinfection  of  articles 
of  clothing,  bedding,  or  merchandise  supposedly  contaminated  by  contact  with 
those  sick  with  the  disease  is  unnecessary. 


12 

A  house  (or  ship)  may  be  said  to  be  infected  with  yellow  fever  only  when 
there  are  present  within  its  walls  contaminated  mosquitoes  capable  of  convey- 
ing the  parasite  of  the  disease. 

The  spread  of  yellow  fever  can  most  effectually  be  controlled  by  measures 
directed  to  the  destruction  of  the  mosquitoes  and  protection  of  the  sick  against 
the  bites  of  these  insects. 

The  commission  showed  also  that  the  mosquito,  to  become  infected, 
must  bite  a  yellow-fever  patient  during  the  first  three  or  four  days 
of  his  illness,  and  that  an  interval  of  about  twelve  days  or  more  after 
this  bite  appears  to  be  necessary  before  the  mosquito  is  capable  of 
communicating  the  disease  to  a  person.  After  this  interval  the  mos- 
quito is  permanently  infected  and  can  cause  the  development  of  the 
disease  within  five  days  after  biting. 

This  conclusion  as  to  the  time  elapsing  from  the  infection  of  the 
mosquito  to  the  time  it  becomes  capable  of  communicating  the  disease 
to  man  is  in  accord  with  and  fully  confirms  the  extensive  observations 
previously  made  by  Surg.  Henry  E.  Carter,  of  the  IT.  S.  Public 
Health  and  Marine-Hospital  Service.  Before  it  was  known  that  the 
mosquito  is  the  carrier  of  the  disease  Surgeon  Carter  proved  "  a 
period  of  extrinsic  incubation  "  corresponding  to  the  cycle  of  devel- 
opment of  the  disease  in  the  mosquito. 

In  1900  yellow  fever  raged  throughout  Cuba  and  was  very  severe 
in  Habana.  During  this  year  and  in  this  city  (Habana)  the  com- 
mission made  the  scientific  investigation  and  obtained  the  results 
which  have  revolutionized  all  theories  as  to  the  prevention  and  spread 
of  yellow  fever.  Witness  the  fact  reported  January  9,  1902,  by  Maj. 
W.  C.  Gorgas,  chief  sanitary  officer  of  Cuba,  that,  with  the  aid  of  a 
corps  of  men,  working  in  accordance  with  the  recommendations  of 
the  commission,  the  disease  has  been  completely  eradicated  from  the 
city  of  Habana. 

The  efficient  maritime  quarantine  maintained  by  the  U.  S.  Public 
Health  and  Marine-Hospital  Service  must  also  be  taken  into  consid- 
eration, for  while  the  disease  was  stamped  out  of  the  city  by  the 
measures  referred  to,  it  was  kept  out  by  similar  measures  directed  to 
the  cleansing  of  ships  and  to  the  isolation  and  protection  of  passen- 
gers arriving  from  other  infected  ports. 

Formerly  the  hotbed  of  yellow  fever  and  for  upward  of  a  hundred 
years  the  very  center  of  infection,  Habana  is  now  free  from  the 
disease,  not  a  single  case  of  yellow  fever  having  occurred  there  during 
the  last  three  years;  and  all  this  as  a  result  of  the  wholesale  destruc- 
tion of  the  mosquitoes  and  their  breeding  places,  in  the  city  and  on 
board  of  ships,  and  the  protection  of  the  sick  by  means  of  properly 
constructed  mosquito  screens. 

Yellow  fever  prevails  chiefly  in  low  countries  along  the  coast,  and 
seldom  extends  to  regions  above  an  elevation  of  1,000  feet.  It  is 


13 

apt  to  be  severe  in  the  slums  or  badly  drained  sections  of  large  cities. 
Filthy,  dark,  and  ill- ventilated  rooms  in  a  house  (or  ship)  seem  to 
invite  the  disease.  Heat  and  moisture  or  dampness  favor  its  develop- 
ment; frost  arrests  it.  The  mosquito  is  inactive  during  cold  or 
frosty  weather.  Or,  quoting  from  Osier,  "  humidity  and  heat  seem  to 
be  the  proper  coefficients  for  the  preservation  of  the  poison.  The 
epidemics  in  the  United  States  have  always  been  in  the  summer  and 
autumn  months,  disappearing  rapidly  with  the  onset  of  cold 
weather." 

Strangers  in  yellow- fever  districts  are  usually  the  first  victims. 
The  negro  is  said  to  be  less  susceptible  than  the  white.  This  appar- 
ent immunity  is  probably  due  to  the  fact  that  the  endemic  regions 
of  yellow  fever  are  populated  chiefly  by  black  or  dark-skinned  races, 
who,  as  Guiteras  has  pointed  out,  have  had  the  disease  in  childhood, 
precisely  as  Koch  has  shown  that  natives  of  highly  malarious  coun- 
tries are  apparently  free  from  malarial  fever  because  of  repeated  and 
persistent  infection  in  early  life.  The  immunity,  then,  of  the  negro 
may  be  said  to  be  the  same  as  that  of  the  white — an  acquired  immunity. 
Nonimmunes  of  either  race  are  probably  equally  susceptible;  or  if 
there  be  a  difference  it  may  apply  to  the  relative  thickness  of  the  skin 
rather  than  to  the  color,  or,  possibly,  to  the  predilection  of  the  mos- 
quito. Stendel,  according  to  Scheube,  "  is  inclined  to  think  that  the 
relative  immunity  of  the  negroes  is  to  be  attributed  to  the  lively  and 
quite  specific  activity  of  their  skin,  distinctly  evidenced  by  the  odor." 

In  1793  yellow  fever  prevailed  extensively  in  Northern  cities,  par- 
ticularly in  Philadelphia,  where  out  of  a  population  of  40,000  (the 
number  of  inhabitants  of  the  city  at  that  time)  more  than  4,000  died. 
Epidemics  occurred  also  in  different  parts  of  the  United  States  during 
the  early  part  of  the  last  century;  but  for  many  years  past  no 
extensive  outbreaks  have  occurred  in  this  country  except  in  the  South- 
ern States,  where  in  1853,  1867,  1873,  1878,  1897,  1898,  and  1899  it 
prevailed  in  different  degrees  of  severity.  The  most  extensive  epi- 
demic occurred  throughout  the  South  in  1878.  It  was  unusually 
severe  in  Alabama,  Louisiana,  and  Mississippi,  and  caused  about 
16,000  deaths.  The  later  epidemics  were  less  severe.  Localized  out- 
breaks occurred  at  different  times  in  nearly  all  the  Southern  States, 
but  the  disease  was  of  milder  type. 

The  disease  is  occasionally  carried  into  northern  latitudes  by 
infected  ships,  but  it  seldom  reaches  port,  being  usually  stopped  at 
the  quarantine  station,  where  the  sick  are  placed  in  hospital,  the  well 
detained  for  observation,  and  the  ship  and  everything  disinfected. 

Symptoms. — Yellow  fever  generally  begins  after  an  incubation 
period  of  three  or  four  days ;  in  13  experimental  cases  it  varied  from 
forty-one  hours  to  five  clays  and  seventeen  hours.  The  onset  is  usually 
sudden.  It  frequently  comes  on  at  night  or  in  the  early  morning,  and 


14 

is  generally,  but  not  always,  ushered  in  by  a  chill,  which  is  followed  by 
moderate  or  high  fever— 101°  to  105°  F.  (38.3°  to  40.5°  C.)  ;  hot  skin, 
quick  pulse  (100  to  1*20  per  minute)  ;  flushed  face,  and  watery,  bril- 
liantly reddened  eyes.  The  tongue  is  usually  moist  and  coated,  but 
soon  becomes  dry  and  pointed.  Thirst  is  marked,  the  throat  is  sore,  the 
stomach  is  irritable,  and  in  most  cases  there  is  nausea  and  vomiting 
from  the  beginning.  The  bowels  are  constipated,  the  stools  dark  col- 
ored. The  urine  is  acid,  scanty,  and  apt  to  be  albuminous,  especially 
the  evening  urine.  The  presence  of  albumen  on  the  first  and  second 
days  indicates  a  severe  case  (Guiteras).  The  fever  may  last  from  a 
few  hours  to  two  or  three  days,  but  while  the  temperature  keeps  up 
the  pulse  steadily  fails.  Death  may  take  place  in  this  early  or  first 
stage  of  the  disease.  Usually  this  stage  is  followed  by— 

.  The  second  stage,  or  stage  of  calm,  as  it  is  called.  During  the  stage 
of  calm  the  fever  goes  down,  the  temperature  drops  in  some  cases 
below  the  normal,  and  the  general  symptoms  subside.  The  skin  may 
or  may  not  be  tinged.  There  is  usually  some  yellowness  of  the  eyes. 
In  the  milder  cases  this  may  be  the  beginning  of  convalescence. 

In  severe  cases  this  stage  of  calm  and  apparent  convalescence  is 
followed,  in  twelve  or  twenty-four  hours,  by— 

The  third  stage,  or  stage  of  febrile  reaction,  when  the  struggle  for 
life  begins.  The  temperature  now  rises  again,  and  the  symptoms  of 
the  first  stage  recur  with  increased  severity,  and  other  and  more 
serious  symptoms  are  developed.  The  jaundice  deepens,  the  pulse 
drops  in  some  cases  to  40  or  even  to  30  per  minute,  vomiting  increases ; 
the  vomited  matter  may  be  bile,  blood,  or  altered  blood  (coffee-grounds 
black).  The  patient  complains  of  severe  abdominal  pain.  The 
stools  are  black  and  frequently  of  tarry  consistence.  The  urine  very 
scanty  and  albuminous.  Bleeding  may  occur  from  the  nose  and  from 
the  mouth  and  gums.  The  strength  rapidly  fails,  and  the  patient 
dies  from  exhaustion. 

In  some  cases  even  when  black  vomit  occurs  a  change  for  the  better 
takes  place  and  the  patient  gradually  recovers,  but  if  black  vomit 
sets  in  early  in  the  disease  it  is  nearly  always  fatal.  In  the  "  walking 
cases  "  a  man  may  be  up  and  about,  complaining  of  only  slight  ail- 
ment, and  be  suddenly  taken  with  black  vomit  and  die. 

Treatment. — The  milder  and  even  the  moderately  severe  cases  may 
easily  be  mistaken  for  other  diseases;  but  if  a  man  is  seized  with  an 
illness  as  above  described,  particularly  if  the  ship  is  or  has  recently 
been  in  a  yellow-fever  district  or  where  }7ellow  fever  is  likely  to 
prevail,  he  should  be  placed  in  a  clean,  well-ventilated  room,  as  far 
removed  as  possibly  from  the  healthy  members  of  the  crew,  and  have 
one  good  and  constant  attendant  or  nurse,  who  may,  if  convenient, 
occupy  an  adjoining  room  when  not  in  actual  attendance  at  the  bed- 
side, but  who  must  be  given  to  understand  that  his  whole  duty  con- 


15 

sists  in  caring  for  the  patient.  The  nurse  should  be  supplied  with 
everything  required  for  the  care  of  the  patient,  but  all  unnecessary 
articles  should  be  removed  from  the  room.  Careful  nursing  in  this 
disease  is  more  than  "  half  the  battle;''  but  for  the  protection  of  the 
nurse  himself  and  for  all  members  of  the  crew  the  one  thing  that 
requires  immediate  attention  is  the  screening  of  the  patient's  bed 
and  the  doors  and  windows  of  his  room,  so  as  to  prevent  the  mos- 
quitos  from  biting  the  sick  person  and  communicating  the  disease  to 
others. 

Yellow  fever  is  sometimes  complicated  with  malarial  fever,  and 
such  complications  may  be  very  serious.  When  near  the  coasts  where 
these  diseases  prevail,  it  is  a  good  plan  to  give  each  man  on  board  a 
daily  allowance  of  quinine,  say  10  grains  (O.G5  gm.).  The  men 
should  also  be  careful  to  keep  their  bowels  regular  and  to  be  regular 
in  their  habits  of  eating  and  sleeping  and  avoid  excitement,  worry, 
or  excessive  fatigue.  They  must  not  be  allowed  to  go  ashore.  Their 
beds  and  sleeping  rooms  should  be  properly  screened  with  mosquito 
netting.  This  will  not  only  be  a  protection  against  a  possible  mala- 
rial complication,  but  will  place  the  body  in  the  best  condition  to 
battle  against  an  attack  of  yellow  fever,  and  may  prevent  an  attack 
of  pernicious  malaria,  which  in  some  of  its  forms  is  as  serious  and 
dangerous  as  yellow  fever  itself. 

As  soon  as  the  attack  of  yellow  fever  begins,  place  the  patient  at 
rest  in  bed  on  a  blanket,  and  immediately  give  him  a  hot  footbath. 
The  foot  tub  should  be  half  full  of  warm  water,  to  which  a  pound  of 
mustard  may  be  added.  The  patient's  feet  and  legs  are  then  placed 
in  the  water,  and  a  quantity  of  very  hot  water  is  added,  so  as  to  make 
the  bath  as  hot  as  he  can  stand  it.  The  bath  must  be  hot,  and  while 
it  is  going  on  the  entire  body  of  the  patient  should  be  covered  with 
blankets,  and  he  should  drink  hot  tea.  After  the  footbath  is  removed, 
the  patient  should  be  allowed  to  perspire  for  ten  minutes.  His  body 
must  then  be  quickly  dried  and  wrapped  in  a  fresh  blanket.  A 
5-grain  (0.33  gm.)  dose  of  calomel  should  then  be  given,  which  may 
be  followed  in  six  hours  by  a  tablespoonful  of  Rochelle  salts  in  a 
glass  of  water,  or  in  place  of  the  calomel  two  compound  cathartic 
pills  may  be  given.  If  vomiting  occur,  a  large  mustard  plaster 
should  be  placed  over  the  region  of  the  stomach  and  small  pieces  of 
ice  in  the  patient's  mouth. 

The  diet  in  yellow  fever  is  very  important.  For  the  first  day  or 
two  very  little  if  anything  is  required.  A  little  milk  diluted  with 
vichy  water  may  be  allowed  every  three  hours.  Later  a  little  broth 
and  very  gradually,  when  the  fever  is  reduced,  other  light  and  easily 
digestible  articles  may  be  given  in  small  quantities  at  regular 
intervals. 

If  the  fever  continues  high  and  the  patient  is  restless,  5  grains  (0.33 


16 

gm.)  of  phenacetin  may  afford  relief,  and,  if  necessary,  a  second  dose 
may  be  given  after  an  interval  of  three  hours.  Vichy  or  other  alka- 
line mineral  water  should  be  given  in  small  quantities  frequently 
repeated.  The  bowels  should  then  be  kept  open  by  means  of  rectal 
injections  of  warm,  soapy  water.  A  long  tube  attached  to  the  syringe 
should  be  passed  into  the  bowels  as  far  as  possible  and  at  least  a  quart 
injected  once  or  twice  a  day. 

If  black  vomit  occur,  give  15  or  20  drops  of  tincture  of  chloride  of 
iron  in  a  little  water  every  three  hours.  Apply  mustard  to  the  stom- 
ach, and  give  cold  champagne  and  'viclty.  or  brandy  and  ice  water. 

Used  clothing,  body  linen,  and  bedding  of  the  patient  and  nurse 
should  be  immersed  at  once  in  boiling  water  or  in  a  disinfecting 
solution. 

*  *  *  "  All  mosquitoes  on  board  should  be  destroyed  by  burning 
pyrethrum  powder  (Persian  insect  powder)  or  by  fumigation  with 
sulphur.  Mosquito  larvae  (wigglers,  or  wiggle  tails)  should  be  de- 
stroyed in  water  barrels,  casks,  and  other  collections  of  water  about 
the  vessel  by  the  use  of  petroleum  (kerosene)  ;  where  this  is  not  prac- 
ticable use  mosquito  netting  to  prevent  the  exit  of  mosquitoes  from 
such  breeding  places."  (U.  S.  Quarantine  Regulations.) 

The  sick  room,  as  soon  as  it  is  vacated,  also  the  room  occupied  by 
the  nurse,  should  be  thoroughly  disinfected  by  burning  sulphur,  2 
pounds  for  every  thousand  cubic  feet  of  air  space,  to  destroy  possibly 
infected  mosquitoes. 

The  sulphur  is  placed  in  an  iron  pot,  the  pot  is  then  set  on  two 
bricks  in  a  tub  containing  a  sufficient  quantity  of  water  to  prevent  the 
burning  sulphur  from  running  on  the  floor  and  setting  fire  to  the 
ship.  The  windows  and  all  crevices  should  be  tightly  closed.  When 
everything  is  ready  the  nurse  should  then  light  the  sulphur,  leave  the 
room  and  close  the  door.  At  the  end  of  twelve  hours  the  doors  and 
windows  should  be  thrown  open.  The  walls  and  ceiling  and  all 
articles  of  furniture  should  then  be  washed  down  with  a  solution  of 
bichloride  of  mercury  (1  to  1,000)  and  the  ship  should  be  taken  to 
the  nearest  quarantine  station  for  thorough  fumigation  to  destroy 
mosquitoes  in  other  parts  of  the  vessel. 

MALARIAL   FEVER. 

Malarial  fever  is  an  endemic  infectious  disease,  caused  by  a  para- 
site of  the  blood.  The  disease  is  transmitted  to  man  (inoculated)  by 
the  bite  of  certain  kinds  of  mosquitos,  of  the  genus  Anopheles. 

The  parasite  in  the  blood  of  persons  sick  with  malarial  fever  was 
discovered  in  1880  by  Laveran,  a  French  surgeon  in  Algiers.  At 
first  repudiated,  the  discovery  was  later  confirmed  by  other  French 
surgeons  and  by  numerous  Italian,  British,  German,  and  American 
investigators. 


17 

After  the  confirmation  of  the  discovery  of  Laveran,  the  very 
important  questions  arose  as  to  the  origin  of  the  malarial  parasites 
and  the  means  by  which  they  enter  the  human  body.  The  answers 
were  soon  forthcoming.  Mansori,  Ross,  and  others  demonstrated 
conclusively  that  the  disease  is  propagated  and  transmitted  from  one 
person  to  another  by  a  certain  kind  of  mosquito. 

"  Doctor  Manson  took  the  advanced  position  that  an  intermediate 
host  in  the  shape  of  a  certain  gnat  or  mosquito  was  necessary  in 
transmitting  the  disease  from  man  to  man  and  was  also  an  inevitable 
portion  of  the  cycle  of  development  of  the  parasite.  No  subject  has 
been  more  carefully  and  elaborately  worked  out;  in  no  research 
known  to  modern  science  have  fanciful  or  theoretical  deductions  been 
the  subject  of  more  careful  scrutiny;  and  to-day  the  'mosquito 
theory  '  of  the  transmission  of  malaria  is  no  longer  a  theory,  but  an 
accepted  fact." — (Geddings.) 

Malarial  fever  is  a  disease  of  warm  and  temperate  regions;  very 
prevalent  and  of  severe  type  in  hot  countries,  especially  along  the 
seacoast  and  basins  of  rivers,  but  gradually  declining  in  extent  and 
virulence  in  proportion  to  the  distance  on  either  side  from  the 
equator.  In  the  Tropics  the  disease  is  constantly  prevalent.  In  the 
cooler,  or  temperate  regions,  as  for  example,  along  the  coast  of  the 
Central  Atlantic  States,  it  is  active  only  during  summer  and 
autumn.  It  is  seldom  developed  at  a  lower  temperature  than  60°  F. 
(15.5°  C.),  and  even  in  the  hot  climates  malaria  is  probably  never 
contracted  far  away  from  land.  The  disease  is  said  to  be  most  fre- 
quently contracted  during  the  night,  just  after  sunset  and  just  before 
sunrise  being  the  most  dangerous  periods.  It  is  therefore  very 
important  in  infected  localities  not  to  permit  the  men  to  go  ashore, 
nor  to  allow  them  to  sleep  on  deck,  if  the  vessel  is  lying  near  the  land ; 
or,  if  they  must  sleep  on  deck  or  other  exposed  places,  to  provide  suit- 
able protection  by  means  of  blankets  and  properly  constructed  mos- 
quito bars.  The  protective  measures  already  referred  to  under  "  yel- 
low fever  "  are  equally  important  in  guarding  against  malaria. 

There  are  different  varieties  and  types  of  malarial  intermittent 
fever:  (1)  Quotidian,  when  the  paroxysm  occurs  every  day;  (2) 
tertian,  when  it  occurs  every  other  day;  and  (3)  quartan,  when  it 
occurs  every  fourth  day.  The  disease  is  popularly  known  as  "  fever 
and  ague,"  "  chills  and  fever,"  "  the  shakes,"'  etc.  It  is  character- 
ized by  recurring  paroxysms,  consisting  as  a  rule  of  three  distinct 
stages:  The  cold,  the  hot,  and  the  sweating  stage.  The  attack  may 
be  sudden  or  it  may  be  preceded  by  a  feeling  of  uneasiness,  a 'desire  to 
stretch  the  limbs  and  yawn,  headache,  loss  of  appetite,  and  some- 
times by  vomiting.  The  chill  may  be  of  any  degree  of  severity. 
Patients  sometimes  complain  only  of  chilliness,  or  of  a  creeping  sen- 
13256—04  M 2 


18 

sat  ion  of  coldness  over  the  back.  More  frequently  the  chill  is  well 
marked;  the  feeling  of  cold  spreads  all  over  the  body,  the  teeth 
chatter,  the  patient  shivers,  and  his  whole  body  shakes.  This  cold 
stage  may  last  from  a  few  minutes  to  an  hour,  or  longer. 

The  hot  stage  gradually  comes  on  as  the  cold  stage  subsides,  and 
soon  there  is  a  feeling  of  intense  heat.  The  face  becomes  flushed, 
the  pulse  full  Or  bounding,  the  headache  continues,  and  the  patient 
is  in  high  fever.  This  stage  may  last  from  half  an  hour  to  four  or 
five  hours,  when  perspiration  appears,  first  on  the  forehead  and 
gradually  over  the  entire  body,  and  the  sweating  stage  is  fully  estab- 
lished. With  the  appearance  of  perspiration  the  fever  declines,  the 
distressing  symptoms  gradually  cease,  the  patient  experiences  a  feel- 
ing of  great  relief,  and  soon  falls  into  a  refreshing  sleep.  The  dura- 
tion of  the  sweating  stage  varies  from  one  to  three  hours.  It  may 
be  very  profuse  or  very  slight.  At  the  end  of  the  sweating  stage  the 
patient  may  be  greatly  prostrated  or  may  feel  quite  well,  and  able 
to  be  up  and  about  until  the  beginning  of  the  cold  stage  of  the  next 
fit,  twenty-four,  forty-eight,  or  seventy-two  hours  from  the  beginning 
of  the  first. 

Besides  the  three  varieties  of  regularly  intermittent  malarial  fever, 
there  are  irregular  forms  of  intermittent;  also  remittents,  bilious 
remittents,  typhoid  remittents  or  typho-malarial,  and  a  very  severe 
type  known  as  pernicious  malarial  fever. 

In  the  irregular  intermittent  the  paroxysms  may  be  longer  and 
recur  at  irregular  intervals,  the  cold  stage  may  be  absent,  the  fever 
may  come  on  gradually  and  decline  to  normal  in  the  same  manner. 

When  the  attacks  are  prolonged,  and  when  instead  of  declining  to 
normal  there  may  be  only  a  slight  fall  in  the  temperature  and  slight 
sweating,  the  fever  is  called  remittent  fever. 

When  a  remittent  fever  is  accompanied  by  recurring  attacks  of 
bilious  vomiting,  constipation,  or  bilious  diarrhea,  and  perhaps  a 
yellowish  tint  of  the  skin  and  eyes,  it  is  said  to  be  bilious  remittent 
fever. 

When  typhoid  symptoms,  such  as  dry  tongue,  low  delirium,  extreme 
prostration,  etc.,  appear  in  conjunction  with  the  ordinary  symptoms 
of  remittent  or  bilious  remittent  fever,  the  disease  is  called  typhoid 
remittent  or  typho-malarial  fever.  This  is  really  the  coexistence  of 
two  diseases,  typhoid  fever  and  malarial  fever. 

Pernicious  malarial  fever,  as  the  name  indicates,  is  a  very  fatal 
disease.  It  occurs  chiefly  in  hot  climates,  but  is  occasionally  met  with 
in  temperate  regions.  It  may  be  preceded  by  an  apparently  mild 
attack  ot  intermittent  fever,  or  the  patient  may  be  taken  suddenly 
with  intense  headache,  high  feA*er.  wild  or  perhaps  muttering  de- 
lirium, rapidly  passing  into  unconsciousness,  and  death  may  occur 
within  a  few  hours  from  the  beginning  of  the  attack. 


19 

In  another  form  of  the  disease  the  attack  begins  with  extreme  cold- 
ness of  the  surface  of  the  body,  with  vomiting,  or  with  severe  diar- 
rhea or  dysentery,  and  the  patient  may  die  from  collapse. 

There  is  also  a  hemorrhagic  form  in  which  bleeding  may  occur 
from  the  nose,  mouth,  or  gums.  The  urine  may  be  bloody  or  quite 
dark  in  color,  in  some  cases  almost  black.  In  tropical  Africa  and 
other  hot  countries  where  the  disease  prevails  it  is  known  as  "  black- 
water  fever." 

Hemorrhages,  however,  may  occur  in  any  severe  or  prolonged  form 
of  malarial  infection,  and  bloody  urine  (malarial  hematuria)  is  not  in- 
frequently met  with. 

Treatment. — Quinine  is  the  remedy,  and  quinine  also  acts  as  a  pre- 
ventive. In  going  to  a  malarial  region,  treatment  should  be  com- 
menced several  clays  before  arriving  at  port.  To  each  man  on  board 
should  be  given  at  least  10  grains  (0.0  gm.)  of  quinine  daily  for  a 
period  of  one  week.  The  allowance  may  then  be  reduced  to  5  grains 
(0.3  gm.)  or  even  to  3  grains  (0.2  gin.)  a  day.  The  bowels  should 
be  kept  freely  open. 

If  a  chill  occur,  the  patient  should  at  once  be  wrapped  in  blankets 
and  given  hot  drinks.  During  the  hot  stage,  cold  drinks,  lemonade, 
etc.,  may  be  given.  As  soon  as  the  sweating  stage  begins,  10  or  15 
grains  (0.0  gm.  to  1  gm.)  of  quinine  should  be  given,  and  thereafter  5 
grains  (0.8  gm.)  every  six  hours,  for  two  or  three  days,  and  then  con- 
tinued in  smaller  doses,  say  8  grains  (0.2  gm.)  three  times  daily,  for 
the  next  two  weeks. 

If  the  chill  is  severe,  or  if  the  surface  of  the  body  is  very  cold,  hot- 
water  bottles  or  heated  bricks  or  stones  wrapped  in  cloth  or  in  a 
separate  piece  of  blanket  should  be  placed  to  the  feet.  Mustard 
plasters  may  also  be  applied  to  the  extremities  and  over  the  region 
of  the  heart,  and  hot  stimulating  drinks  should  be  given. 

If  vomiting  occurs,  a  mustard  plaster  may  also  be  placed  over  the 
region  of  the  stomach,  above  the  navel,  and  cracked  ice  may  be  given 
by  the  mouth.  Headache  may  be  relieved  by  cold  applications. 

If  the  hot  stage  is  severe,  a  tepad  bath  may  be  given  in  a  tub  or  by 
means  of  a  sponge.  If  the  temperature  is  very  high,  105°  or  100°  F. 
(40.5°  or  41.1°  C.),  a  cold  bath  should  be  given. 

For  extreme  pain  or  restlessness,  a  pill  of  morphine  sulphate  one- 
sixth  grain  (0.01  gm.),  or  12  drops  of  tincture  of  opium  (laudanum), 
or  10  grains  (0.0  gm.)  of  Dover's  powder  may  be  given,  and  if  neces- 
sary repeated  in  three  hours. 

In  bilious,  remittant,  and  other  severe  types  of  malarial  fever  the 
treatment  should  be  more  active.  No  time  should  be  lost  in  giving 
the  quinine;  10  or  15  or  20  grains  (0.6  gm.  to  1.3  gm.)  should  be 
given  immediately,  and  along  with  this,  if  the  bowels  are  not  freely 
open,  5  or  10  grains  (0.3  gm.  to  0.0  gm.)  of  calomel.  After  the 


20 

bowels  move,  the  quinine  should  be  continued  in  5-grain  (0.3  gm.) 
doses  every  four  or  five  hours. 

If  there  is  much  vomiting  and  if  the  medicine  is  not  retained,  an 
emetic  of  lukewarm  water  or  powdered  ipecac  should  be  given,  and 
after  waiting  a  little  while  the  quinine  and,  if  necessary,  the  calomel 
may  be  tried  again.  Mustard  plaster  to  the  region  of  the  stomach, 
cracked  ice  in  the  mouth,  sips  of  very  hot  water,  or  a  little  cham- 
pagne may  have  a  good  effect  on  the  vomiting.  If,  notwithstanding 
these  measures,  the  A^omiting  continues  and  the  medicine  is  imme- 
diately rejected,  the  rectum  should  be  washed  out  with  an  injection  of 
warm  water,  and  then  at  least  30  grains  (2  gm.)  of  quinine  in  2  or  3 
ounces  of  water  should  be  injected  into  the  rectum.  When  the  stom- 
ach is  settled  5-grain  (0.3  gm.)  doses  of  quinine  may  be  given  again 
by  the  mouth. 

The  best  method  of  giving  quinine  for  rapid  effect  and  perhaps  the 
be:st  means  of  saving  life  in  the  severe  pernicious  forms  of  malarial 
fever  is  to  give  the  quinine  hypodermically  (injected  under  the  skin 
by  means  of  a  hypodermic  syringe).  But  this  method  is  out  of  the 
question  except  in  the  hands  of  an  experienced  person,  and  even  then 
it  is  apt  to  produce  abscesses. 

The  symptoms  and  signs  of  typical  malarial  intermittent  fever  are 
so  striking  that  they  can  hardly  be  mistaken  for  anything  else.  It 
must  not  be  forgotten,  however,  that  there  are  typical  and  irregular 
forms  of  malarial  fever,  and  that  they  may  be  mistaken  for  other 
diseases,  such  as  tubercle  (consumption)  of  the  lungs,  abscess  of  the 
lungs  or  of  the  liver  or  any  part  of  the  body,  or  the  result  of  the 
passing  of  a  catheter,  all  of  which  produce  chills  or  chilliness  and 
fever. 

Some  forms  of  remittent  or  continued  remittent  malarial  fever 
may  be  difficult  to  distinguish  from  typhoid  fever,  and  if  the  patient 
is  suffering  from  the  poison  of  malarial  fever  and  typhoid  fever  at 
the  same  time  he  will  have  typho-malarial  fever.  The  bilious  remit- 
tent type  may  be  mistaken  for  yellow  fever. 

Quinine  is  the  remedy  for  any  form  of  malarial  fever.  If  the 
fever  does  not  yield  to  full  doses  of  quinine,  it  is  probably  not  mala- 
rial. At  any  rate  this  is  the  most  practical  method  for  determining 
the  question  as  to  whether  the  fever  is  malarial  or  not.  In  the  hos- 
pital or  laboratory  the  diagnosis  is  made  by  microscopical  examina- 
tion of  the  blood. 

The  diet  in  any  form  of  acute  fever  should  be  light,  liquid,  and 
nourishing,  and  if  there  is  much  prostration  stimulants  will  be 
required.  Solid  food  should  not  be  allowed.  After  the  fever  has 
subsided  a  tonic  should  be  given  (a  teaspoonful  of  elixir  of  iron, 
quinine,  and  strychnia  three  times  a  day,  or  10  drops  of  the  tincture 
of  chloride  of  iron  in  a  wineglassful  of  water  three  times  daily). 


21 

SMALLPOX. 

Smallpox  is  an  acute,  contagious,  self-limited  disease,  character- 
ized by  an  initial  fever  and  successive  stages  of  eruption.  It  spreads 
rapidly  among  persons  unprotected  by  vaccination.  It  may  be  com- 
municated by  the  breath,  by  exhalations  from  the  skin,  by  clothing, 
or  by  anything  that  has  been  in  contact  with  a  person  suffering  from 
the  disease.  It  is  very  contagious  during  the  latter  stage  of  eruption, 
and  especially  during  the  period  of  convalescence  when  the  dried  pus 
scales  become  detached  from  the  skin  and  in  the  form  of  dry  powder 
or  dust  settle  on  everything  about  the  room  or  compartment,  and  may 
be  conveyed  not  only  to  all  parts  of  the  ship,  but  to  any  part  of  the 
world  to  which  the  ship  is  bound. 

After  a  period  of  incubation  of  from  eight  to  fourteen  days, 
occasionally  longer,  the  disease  begins  suddenly,  usually  with  a  chill, 
always  with  severe  pain  in  the  back  and  loins,  intense  headache,  and 
high  fever.  Vomiting  occurs  in  many  cases.  The  bowels  may  or 
may  not  be  constipated. 

About  the  end  of  the  third  day  or  on  the  fourth  day  a  papular 
eruption  appears  on  the  forehead,  and  frequently  on  the  lips  and  the 
wrists,  occasionally  in  the  mouth  and  throat,  and  gradually  extends 
to  other  parts  of  the  body.  The  eruption  begins  as  a  bright  red  dot 
or  spot  slightly  elevated  above  the  surrounding  skin,  enlarging  until 
the  second  day,  when  it  forms  a  papule.  The  papule  is  hard  to  the 
touch,  feels  like  shot  under  the  skin.  As  soon  as  the  eruption  appears 
the  temperature  begins  to  fall,  and  the  distressing  symptoms  subside. 
On  the  fifth  or  sixth  day  a  small  vesicle,  with  a  depression  of  the  cen- 
ter, appears  on  the  top  of  each  papule.  The  vesicles  gradually  become 
distended,  the  depressed  centers  rounded  out,  and  about  the  eighth  or 
ninth  day  the  change  is  completed  and  the  vesicles  become  pustules. 
They  have  a  yellowish  gray  appearance  and  each  pustule  is  sur- 
rounded by  a  red  border.  The  skin  between  them  is  swollen,  the  eyes 
may  be  closed.  During  this  change  the  temperature  rises  again,  sec- 
ondary fever  sets  in,  the  chief  symptoms  return,  and  a  day  or  two  later 
another  change  begins.  The  pustules  break,  matter  oozes  out,  crusts 
form,  first  on  the  face  and  then  over  other  parts  of  the  body  following 
the  order  of  the  appearance  of  the  eruption.  The  secondary  fever 
may  be  quite  high  in  the  beginning,  but  gradually  declines  as  the 
pustules  change  into  crusts,  and  in  favorable  cases  seldom  lasts  more 
than  two  or  three  days.  The  crusts  then  rapidly  dry  and  fall  off, 
leaving  red  spots  on  the  skin,  and  here  and  there  the  characteristic 
pockmarks  or  pits.  The  healing  of  the  pustules  is  usually  attended 
by  troublesome  itching, 

In  some  cases  a  diffuse  redness  of  the  skin  or  red  spots  appear  on 
the  abdomen,  or  on  the  side  of  the  chest,  or  on  the  inner  surface  of 


22 

the  thighs  as  early  as  the  second  day,  but  the  distinctive  papular 
eruption  makes  its  appearance  as  stated  at  the  end  of  the  third  or 
on  the  fourth  day,  and  nearly  always  begins  on  the  forehead. 

In  the  confluent  form  of  smallpox  the  eruption  may  appear  a  day 
earlier  and  all  the  symptoms  are  more  severe.  The  pustules  run 
together  and  form  large  brownish  scabs,  chiefly  on  the  face  and  head, 
but  also  on  the  hands  and  feet.  The  face  and  neck  are  greatly  swol- 
len, the  eyes  are  closed,  the  features  are  distorted.  The  patient  com- 
plains of  tension  and  burning  of  the  skin ;  there  is  much  thirst.  The 
eruption  may  also  appear  in  the  mouth  and  throat.  The  secondary 
fever  is  high.  Delirium  may  be  quite  marked.  In  fatal  cases  the 
pulse  becomes  rapid  and  feeble,  and  death  occurs  about  the  tenth  or 
eleventh  day  or  later. 

In  favorable  cases,  about  the  eleventh  or  twelfth  da}r  the  pustules 
begin  to  break.  The  matter  dries  and  forms  crusts  which  slowly  fall 
off,  leaving  the  skin  quite  red  and  in  many  cases  dreadfully  scarred 
and  pitted. 

The  crusts  begin  to  drop  off  about  the  fourteenth  day,  but  the  proc- 
ess of  desquamation  may  not  be  completed  until  the  end  of  the  third 
or  fourth  week,  and  the  fever  may  persist  during  that  period.  In 
some  cases  the  entire  skin  of  the  hands  is  cast  off  like  a  glove,  and  the 

O 

skin  of  the  feet  and  toes  may  be  shed  in  a  similar  manner.  There  is  a 
milder  form  of  smallpox  called  rarioloid,  in  which  the  symptoms  are 
usually  milder  and  of  shorter  duration.  Varioloid  occurs  in  persons 
who  have  been  vaccinated.  Sometimes  the  eruption  begins  on  the 
feet.  In  some  cases  it  is  confined  to  the  feet  and  hands.  Occasionally 
the  eruption  is  extensive  and  the  symptoms  arc  severer 

The  most  severe  type  of  smallpox  is  the  hemorrhagic  (bloody).  It 
occurs  in  two  forms.  In  one  the  case  goes  on  in  the  usual  way  until 
about  the  ninth  or  tenth  day,  wThen  blood  makes  its  appearance  in  the 
pock.  This  form  is  sometimes  called  black  smallpox.  In  the  other 
form  the  eruption  may  be  blood-colored  from  the  second  day,  and 
bleeding  may  take  place  from  the  nose  or  mouth  or  from  the  rectum. 
The  face  is  greatly  swollen  and  the  eyes  are  deeply  bloodshot.  Death 
occurs  during  the  first  week,  sometimes  as  early  as  the  second  day. 

Before  the  characteristic  eruption  appears  it  is  frequently  very 
difficult  to  determine  the  existence  of  smallpox.  It  is  easily  con- 
founded with  other  eruptive  diseases.  The  important  points  to 
remember  are  the  intense  pain  in  the  back,  the  high  fever,  and 
bounding  pulse,  all  of  which  precede  the  eruption,  and  that  when 
the  eruption  appears  the  fever  and  all  the  severe  symptoms  subside. 
The  temperature  before  the  eruption  may  be  up  to  105°  or  106°  F. 
(40.5°  or  41.1°  C.)  When  the  eruption  appears  it  begins  to  decline, 
and  within  twenty-four  or  thirty-six  hours  is  down  to  about  100°  F. 


23 

(37.7°  C.)  When  the  secondary  fever  sets  in  the  temperature  rises 
again. 

Treatment. — The  patient  should  be  placed  in  a  cool,  well-ventilated 
room,  and  strictly  isolated;  and  every  person  on  board  should  be 
immediately  vaccinated.  No  one  should  be  allowed  to  come  in  con- 
tact with  him  except  the  nurse  or  attendant,  and  the  nurse  or  attend- 
ant should  not  be  allowed  to  come  in  contact  with  other  members 
of  the  crew.  While  in  immediate  attendance  on  the  sick  he  should 
wear  overalls  and  jumper,  and  a  head  covering,  to  be  removed 
when  he  leaves  the  room,  and  immediately  put  on  again  when  he 
returns.  Separate  dishes  and  necessary  utensils  should  be  pro- 
vided. The  food  should  be  placed  at  a  convenient  place  near  the 
door  of  the  sick  room  where  the  nurse  can  come  and  get  it.  Noth- 
ing should  be  allowed  in  the  room  except  the  articles  absolutely 
necessary.  The  soiled  clothing  should  be  wrapped  in  a  clean  sheet 
(or  in  a  sheet  that  has  been  dipped  in  a  2  per  cent  solution  of  car- 
bolic acid  and  wrung  out),  and  the  bundle  placed  in  a  kettle  of  water 
and  thoroughly  boiled.  If  there  is  a  sufficient  supply  of  bedclothing 
on  board,  the  soiled  articles  should  be  destroyed  by  fire  (burned). 
The  patient  must  be  kept  thoroughly  clean.  Good  nursing  is  very 
important. 

In  the  early  stage,  when  the  fever  is  high,  place  the  patient  in  a 
cold  bath,  or  give  him  a  cold  sponge  bath,  note  the  temperature  of 
the  body,  and  repeat  the  bath  every  three  hours  if  the  thermometer 
registers  above  103°  F.  (39.4°  C.).  If  the  bowels  are  constipated, 
give  small  doses  of  Epsom  or  Rochelle  salts  every  two  or  three  hours. 
If  diarrhea  is  troublesome,  give  teaspoonful  doses  of  paregoric 
every  two  or  three  hours  until  it  is  checked. 

For  the  severe  pain  in  the  back  a  tablet  of  morphine,  \  grain 
(0.01  gm.),  may  be  given,  and,  if  necessary,  repeated  in  two  hours. 
The  food  should  be  soft  and  nourishing  and  given  at  regular  intervals. 
Cold  drinks,  lemonade,  barley  water,  etc.,  may  be  freely  given. 

The  pain  and  tension  in  the  skin  may  be  relieved  by  cold  applica- 
tions. A  piece  of  lint,  wet  with  a  cold  2  per  cent  solution  of  carbolic 
acid,  may  be  applied  to  the  face  and  frequently  renewed.  Holes 
should  be  cut  into  the  lint  corresponding  to  the  eyes,  nose,  and  mouth, 
and  oiled  silk  may  be  placed  on  top.  When  the  pustules  begin  to 
form  it  is  a  good  plan  to  touch  each  one  with  tincture  of  iodine  (a 
camel's  hair  brush  may  be  used  for  the  purpose),  and  a  day  later  to 
puncture  them  with  the  point  of  a  needle.  The  needle  should  first 
be  boiled,  and  the  point  should  then  be  dipped  in  tincture  of  iodine 
before  making  the  puncture.  When  crusts  begin  to  form,  olive  oil  or 
glycerin  should  be  applied.  If  the  hair  is  long  it  should  be  cut  short 
early  in  the  disease  before  the  pustular  stage  begins.  The  eyes  must 
be  carefully  cleansed  several  times  a  day,  else  blindness  may  follow. 


24 

A  solution  of  borax,  5  grains  to  a  fluid  ounce  of  water  (0.33  gm.  to 
30  c.  c.),  is  a  good  eyewash.  The  mouth,  throat,  and  nose  also  re- 
quire attention.  A  saturated  solution  of  chlorate  of  potassium  may 
be  used  as  a  mouth  wash  and  gargle. 

When  the  crusts  and  scabs  drop  off  they  should  be  carefully  gath- 
ered up  and  burned.  The  patient  should  then  have  a  daily  bath  with 
carbolic  soap  and  water.  When  the  case  is  ended  the  room  and  all 
exposed  articles  must  be  disinfected  by  burning  sulphur  (4  pounds 
to  every  1,000  cubic  feet  of  air  space) . 

If  near  port  when  the  disease  breaks  out  the  ship  should  be  taken 
direct  to  the  quarantine  station,  where  the  patient  may  be  taken  care 
of  and  the  ship  disinfected. 

CHOLERA  (EPIDEMIC  CHOLERA,  ASIATIC  CHOLERA). 

Cholera  is  an  infectious  disease,  caused  by  a  specific  organism,  dis- 
covered in  1884  by  Koch,  of  Berlin,  Germany,  and  named  Comma 
bacillus,  because  its  shape,  as  seen  under  the  microscope,  is  not  unlike 
that  of  a  comma. 

Cholera  is  not  endemic  in  any  part  of  the  world  except  Asia.  Its 
home  is  in  India,  where  in  certain  localities  it  has  been  endemic  prob- 
ably for  centuries. 

The  first  widespread  epidemic  is  said  to  have  occurred  in  that  coun- 
try in  the  year  1817.  During  the  years  1830  and  1832  extensive  epi- 
demics occurred  in  different  parts  of  Europe  and  there  were  recur- 
rences of  smaller  epidemics  up  to  1838.  In  the  j^ear  1832  the  disease 
was  brought  to  the  United  States  in  emigrant  ships  from  Great 
Britain  via  Quebec;  also  by  ships  entering  at  New  York.  In  1835-36 
it  again  appeared  in  the  United  States;  in  1846  there  was  another 
widespread  epidemic  in  Europe.  In  1848  it  entered  the  United 
States  through  the  port  of  New  Orleans  and  overspread  the  Missis- 
sippi Valley  and  extended  across  the  continent  to  California.  In 
1854  it  Avas  again  introduced  into  the  United  States  through  the  port 
of  New  York  and  a  widespread  epidemic  was  the  result.  In  1866 
the  disease  was  again  epidemic  in  Europe,  also  in  Arabia  and  Egypt, 
and  during  the  same  year  and  the  year  following,  and  again  in  1873, 
smaller  epidemics  occurred  in  the  United  States.  In  1883-84  an 
extensive  epidemic  prevailed  in  Europe,  particularly  in  France  and 
Italy.  The  last  serious  epidemic  occurred  in  Europe  in  1892  and 
1893,  chiefly  in  Hamburg,  where  it  attacked  nearly  18,000  persons, 
and  more  than  7,000  died  within  a  period  of  three  months.  In  1892 
a  few  cases  were  brought  to  New  York  Harbor,  but  there  was  no 
spread  of  the  disease. 

Every  epidemic  of  cholera  is  probably  due  to  a  spread  of  the  dis- 
ease directly  or  indirectly  from  its  home  in  India.  It  is  apt  to  be 


25 

developed  in  the  wake  of  moving  masses  of  human  beings.  It  fol- 
lows the  great  lines  of  travel  to  different  parts  of  the  world.  It  is 
spread  probably  through  the  agency  of  the  dejections  from  cholera 
patients,  which  contain  the  comma  bacilli.  These  find  their  way 
into  the  water  supply,  or  become  attached  to  different  articles  of 
food  and  are  then,  in  turn,  introduced  through  the  mouth  into  the 
systems  of  health}7  persons.  They  may  be  conveyed  in  clothing,  or 
in  merchandise  of  different  kinds.  An  infected  ship  may  carry  the 
disease  from  one  end  of  the  world  to  the  other. 

An  attack  of  cholera  may  be  of  any  degree  of  severity.  The  symp- 
toms usually  begin  after  a  period  of  incubation  of  from  two  to  five 
days.  The  mildest  forms  are  called  choleraic  diarrhea.  The  stools 
are  watery,  rather  large,  and  of  yellowish  color,  and,  in  the  absence  of 
other  symptoms  of  true  cholera,  may  be  mistaken  for  ordinary  diar- 
rhea, or  the  attack  may  begin  with  colicky  pains,  purging  and  vomit- 
ing as  in  cholera  morbus. 

All  such  symptoms  occurring  in  persons  who  have  been  ashore  at 
infected  ports,  or  who  have  drunk  water  taken  at  such  ports,  should 
be  regarded  as  extremely  suspicious.  Under  ordinary  circumstances 
it  is  difficult  to  distinguish  between  severe  cases  of  cholera  morbus 
and  genuine  cholera.  Cholera  morbus  is  usually  due  to  indigestible 
food  or  other  irritating  exciting  cause,  and  while  true  cholera  may 
not  be  ascribed  to  such  a  cause,  persons  with  weak  or  irritable  stom- 
achs are  more  apt  to  be  attacked  by  cholera  than  are  healthy  persons. 

The  majority  of  cases  of  cholera  begin  with  looseness  of  the  bowels, 
or  an  apparently  simple  diarrhea.  After  a  day  or  two,  or  within  an 
hour  or  two,  the  diarrhea  may  become  very  violent.  The  evacuations 
soon  lose  their  yellowish  color  and  assume  the  grayish-white  appear- 
ance known  as  "  rice-water  stools."  Severe  cramps  occur  in  the  feet 
and  calves  of  the  legs,  and  sometimes  in  the  hands  and  arms.  Vomit- 
ing soon  follows.  There  is  a  burning  sensation  in  the  stomach  and 
the  thirst  is  unquenchable.  The  urine  is  suppressed.  Large  quan- 
tities of  fluid  may  gush  from  the  mouth  as  well  as  from  the  rectum, 
the  patient  sinks  into  a  condition  of  collapse.  The  skin  becomes  cold 
and  covered  with  a  clammy  sweat.  The  tongue  is  coated  and  cold  to 
the  touch,  the  voice  becomes  very  faint  and  husky,  the  breath  icy. 
The  whole  body  shrinks.  The  temperature  in  the  mouth  may  fall 
from  5°  to  10°  below  normal,  while  in  the  rectum  it  may  rise  several 
degrees  above  normal.  The  intellect  usually  remains  clear  until  near 
the  end. 

In  the  very  serious  forms  of  cholera  the  patient  may  fall  into  col- 
lapse and  die  within  an  hour  from  the  beginning  of  the  attack. 

In  the  milder  forms,  or  if  the  patient  survive  the  collapse  of  the 
severe  forms,  the  symptoms  gradually  subside,  the  skin  becomes 
warm,  the  pulse  stronger,  the  urine  is  again  passed,  the  stools  become 


26 

more  natural,  and  the  patient  recovers.  But  there  may  be  a  relapse 
or  the  reaction  may  be  too  severe  and  a  low  type  of  fever,  called 
cholera-typhoid,  may  be  developed  and  prove  fatal  within  a  few  days. 

Treatrnent. — During  the  prevalence  of  an  epidemic  of  cholera,  or 
while  in  the  vicinity  of  ports  on  the  Indian  coast,  where  the  disease  is 
endemic,  every  case  of  mildest  diarrhea,  looseness  of  the  bowels,  or 
irritable  stomach  should  receive  the  most  careful  attention,  for  the 
reason  that,  as  already  stated,  cholera  usually  begins  with  such  symp- 
toms; and  if  the  infection  is  brought  on  board,  the  men  with  bowel  or 
stomach  trouble  of  any  kind  are  usually  the  first  victims  to  the  dread 
disease.  Kest  in  bed,  good  ventilation,  simple  diet,  and  clean  sur-* 
rouridings  must  be  insisted  upon  from  the  very  start.  The  drinking 
water  must  be  boiled.  The  patient  should  be  carefully  isolated  and 
everything  brought  into  contact  with  him  or  contaminated  by  his 
excretions  must  be  disinfected.  The  stools  should  be  passed  into  a 
chamber  containing  a  5  per  cent  solution  of  carbolic  acid,  or  a  10  per 
cent  solution  of  chloride  of  lime.  The  linen  and  bedclothes  should  be 
disinfected  by  dry  heat,  or  by  steam,  212°  F.  (100°  C.)  or  by  boiling. 
The  spoons,  knives,  plates,  and  utensils  of  any  kind  should  be  boiled 
immediately  after  they  are  used. 

The  medicinal  treatment  in  the  first  stages  of  true  cholera  is  about 
the  same  as  for  cholera  morbus,  already  described.  Opium  (lauda- 
num), or  morphine,  or  "  Hot  Drops"  are  the  remedies  chiefly  to  be 
relied  upon,  but  none  of  these  medicines  should  be  given  during  the 
stage  of  collapse. 

Brandy  and  water,  in  small  quantities  at  a  time,  hot  coffee,  and  tea 
are  valuable  in  this  stage.  Brandy  and  warm  water,  or  coffee  or  tea 
should  be  injected  into  the  rectum.  Warm  water  should  also  be 
injected  into  the  rectum  through  a  long  soft-rubber  tube  or  large 
catheter  attached  to  a  Davidson  or,  preferably,  a  fountain  syringe. 
A  1  or  2  per  cent  solution  of  tannic  acid  (tannin)  is  also*  recom- 
mended. One  or  two  quarts  may  be  slowly  introduced.  The  patient 
should  be  wrapped  in  warm  blankets  and  have  hot-water  bags,  hot 
'bottles,  or  hot  bricks  placed  to  his  extremities  and  alongside  his  body 
(careful  of  course  not  to  have  them  too  hot,  lest  great  harm  be  done 
by  burning  the  skin). 

A  ship  with  cholera  on  board  should  go  to  the  nearest  quarantine 
station  for  treatment,  not  only  for  treatment  of  the  sick,  but  also  for 
the  well,  and  above  all  for  the  treatment  of  the  ship,  so  as  to  prevent 
further  spread  of  the  disease. 

THE    PLAGUE. 

Plague,  the  most  dangerous  of  all  infectious  diseases,  is  caused  by 
a  specific  micro-organism  (the  bacillus  pestis  bubonica)  discovered 
in  1894  by  Kitasato,  a  Japanese  physician. 


27 

"  Plague  was  known  to  the  ancients,  and  at  different  times  since 
the  beginning  of  the  Christian  era  hundreds  of  thousands  of  people 
of  the  Old  World  have  been  carried  off  by  its  ravages.  It  has 
probably  always  existed  in  the  Orient,  more  especially  in  India, 
where  it  is  now  raging  in  terrible  epidemic  form. 

"  Plague  is  a  disease  of  hot  countries,  but  it  may  occur  in  any  coun- 
try or  be  carried  to  any  country  in  any  season  of  the  year.  The  most 
widespread  and  disastrous  epidemics  occurred  in  Europe  during  the 
sixth,  fourteenth,  seventeenth,  and  eighteenth  centuries,  and  since 
then  epidemics  of  varying  degrees  of  severity  have  occurred  in  dif- 
ferent parts  of  the  Old  World — in  Europe,  Africa,  and  Asia.  Of  late 
years  the  disease  has  also  appeared  in  South  America  and  Mexico. 
It  has  never  gained  a  foothold  in  the  United  States,  except  the  local- 
ized epidemic  in  the  Chinese  quarter  of  San  Francisco." 

The  disease  is  commonly  called  buhontc  /^n/iic  for  the  reason  that 
in  the  large  majority  of  cases  buboes  (inflamed  and  enlarged  lym- 
phatic glands)  form  in  the  groins.  But  there  is  another  and  more 
fatal  form  of  the  disease,  known  as  Kepti<-«-in'tr  i>In</ne,  in  which 
buboes  are  not  apparent.  Cases  of  this  form  run  such  a  rapid  course 
that  the  patient  dies  of  septicaemia  (blood  poisoning)  before  the 
buboes  appear. 

There  is  also  a  very  dangerous  and  fatal  form  of  the  disease  recog- 
nized as  pneumonic  plague.  This  form  begins  not  unlike  that  of  a 
pneumonia;  the  sputum  is  very  bloody,  and  contains  multitudes  of 
the  bacilli. 

Buboes  occur  in  about  75  per  cent  of  all  cases,  chiefly  in  the  groin, 
but  also  in  the  armpit  and  neck  and  occasionally  about  the  elbow  and 
the  knee  joint.  They  are  usually  developed  by  the  third  or  fourth 
day,  sometimes  within  the  first  twenty-four  hours ;  occasionally  as  late 
as  the  second  week.  They  vary  in  size  from  a  marble  to  a  goose  egg, 
and  as  a  rule  are  very  painful.  Sometimes,  after  attaining  a  con- 
siderable size,  the  buboes  are  absorbed;  more  frequently  they  sup- 
purate and  break.  Small  boils  or  abscesses  may  form  on  different 
parts  of  the  body.  In  some  cases  dark-colored  spots  (petechia)  from 
slight  hemorrhages  form  in  or  beneath  the  skin.  Hemorrhages  may 
also  occur  from  the  nose  or  mouth  or  from  any  mucous  membrane. 

The  bacilli  are  found  in  the  buboes,  blood,  and  internal  organs. 
They  enter  the  body  through  the  respiratory  and  digestive  tracts,  or 
by  way  of  abrasions  or  small  injuries  of  the  skin.  Many  of  the  lower 
animals  suffer  equally  with  man.  Rats  are  the  chief  carriers  of  the 
disease  from  house  to  house  or  from  dock  to  ship.  Most  epidemics 
of  human  plague  are  preceded  by  wholesale  deaths  among  the  rats. 
The  infection  may  be  spread  by  fleas,  flies,  mosquitoes,  and  other 
insects,  or  by  means  of  infected  articles  of  clothing,  bedding,  .etc.,  or 
by  the  food  and  drinking  water  taken  at  infected  ports. 


28 

Symptoms. — The  incubation  period  of  the  plague  varies  from  two 
to  ten  days.  Occasionally  the  onset  of  the  actual  disease  is  preceded 
by  prodromal  symptoms  lasting  from  twelve  to  thirty-six  hours,  char- 
acterized by  chilliness,  headache,  nausea,  congestion  of  the  eyes,  nose- 
bleed, giddiness,  an  anxious  and  painful  expression  of  the  face,  mental 
depression,  and  sometimes  dull  pain  in  the  groin  and  armpits. 

In  most  cases,  however,  bubonic  plague  begins  suddenly  with  fever, 
which  may  or  maA7  not  be  preceded  by  a  chill.  The  temperature  rises 
rapidly  and  reaches  its  highest  point,  105°  or  106°  F.  (40.5°  to 
41.1°  C.)  on  the  second  or  third  day.  The  pulse,  at  first  full,  rapidly 
becomes  small  and  weak,  and  the  beats  vary  from  one  hundred  to  a 
hundred  and  fifty  or  more  per  minute.  The  tongue,  at  first  moist 
and  red  or  white  coated,  soon  becomes  dry  and  brown,  and  dark- 
colored  crusts  (sordes)  may  form  on  the  teeth,  lips,  and  nostrils. 
Delirium  or  coma  is  apt  to  set  in.  Prostration  is  extreme,  and  the 
patient  may  die  in  this  early  stage  before  the  bubo  attains  any  con- 
siderable size,  or,  as  in  the  septicsemic  form  of  the  disease,  without 
the  appearance  of  the  bubo  at  all. 

In  some  cases  on  the  third  or  fourth  day  the  temperature  drops  a 
degree  or  two,  but  generally  rises  again  until  about  the  fifth  or  sixth 
day,  when  it  suddenly  drops  to  normal  or  subnormal.  Death  may 
or  may  not  take  place  in  this  stage.  More  frequently  there  is  a  sud- 
den rise  in  the  temperature  immediately  preceding  death,  and  in 
favorable  cases  the  temperature  falls  to  the  normal  gradually. 

About  70  per  cent  of  all  cases  die  within  the  first  six  days.  Sur- 
vival of  the  sixth  day  may  therefore  be  regarded  as  a  hopeful  sign. 
In  cases  which  tend  to  recovery  the  symptoms  improve  gradually. 
Convalescence  is  slow,  and  at  the  seat  of  the  bubo  an  indolent  sore 
may  be  left,  which  is  very  slow  to  heal. 

Treatment. — Plague  is  a  filth  disease.  A  clean  ship  and  personal 
cleanliness  are  therefore  of  the  greatest  importance. 

If  the  disease  breaks  out  the  patient  should  be  immediately  isolated 
in  a  clean  and  well-ventilated  compartment,  and  the  ship  should  be 
thoroughly  disinfected.  All  articles  in  the  forecastle  or  elsewhere 
on  board  and  not  absolutely  necessary  for  use  should  be  destroyed. 
Articles  of  clothing  or  bedding  soiled  by  the  discharges  of  the  patient 
or  which  have  been  in  close  contact  with 'the  body  should  be  burned 
or  thrown  overboard  and  sunk;  other  articles  of  clothing  should  be 
disinfected  by  steam  212°  F.  (100°  C.)  or  by  boiling,  and  always 
dried  in  the  sunshine  and  open  air.  All  rats  and  vermin  of  every 
kind  should  be  destroyed.  The  discharges  from  the  patient — urine, 
feces,  vomit,  or  sputum — should  be  passed  into  bowls  or  pots  contain- 
ing a  5  per  cent  solution  of  carbolic  acid  or  10  per  cent  solution  of 
chloride  of  lime  or  ordinary  milk  of  lime. 

The  person  detailed  to  wait  on  the  patient  should  be  free  from 


29 

sores  or  scratches  of  any  kind,  and  should  exercise  the  most  scru- 
pulous care  of  his  hands,  and  all  articles  brought  into  contact  with  the 
patient  should  be  disinfected. 

Medicinal  treatment. — Constipation  should  be  relieved  by  calomel, 
5  grains  (0.3  gm.),  followed  in  five  hours  by  a  dose  of  Rochelle  or 
Epsom  salts.  Stimulants  should  be  given  from  the  beginning;  the 
food  should  be  concentrated  and  nourishing.  If  diarrhea  is  per- 
sistent it  may  be  relieved  by  salol  in  5-grain  (0.3  gm.)  doses,  given 
every  three  hours. 

Ice  or  cold  water  should  be  applied  to  the  aching  head  and  the  hot 
body  sponged  with  cold  or  tepid  water.  In  the  earlier  stage  of  the 
buboes  the  local  application  of  ice  is  useful.  Later  on,  if  softened, 
they  should  be  incised  and  dressed  with  iodoform  gauze!  Pain  and 
restlessness  may  be  relieved  by  morphine,  \  grain  (0.01  gm.),  repeated 
in  two  hours  if  necessary. 

The  ship  should  be  taken  to  the  nearest  quarantine  for  necessary 
treatment,  and  especially  to  give  the  survivors  the  best  chance  for  life. 

KKRiKKRi  (THE  KAKKE  OF  .IAPAX). 

Beriberi  is  a  form  of  multiple-neuritis  (inflammation  of  nerves), 
characterized  by  numbness^  tenderness,  and  <rdenm  (dropsical  swell- 
ing) of  the  legs  and  other  parts  of  the  body;  by  irritability  of  the 
heart,  extreme  weakness,  and  paralysis. 

It  occurs  in  epidemic  form  or  as  an  endemic  in  most  tropical  and 
subtropical  climates,  and  is  not  infrequently  carried  into  temperate 
latitudes.  It  is  not  contagions  in  the  ordinary  sense  of  the  term, 
but  may  be  communicated  from  one  person  to  another.  Like  other 
forms  of  infectious  or  epidemic  disease,  beriberi  is  apt  to  break  out 
in  overcrowded  places,  as,  for  example,  in  jails  and  asylums. 

For  the  purpose  of  this  article,  however,  beriberi  is  to  be  regarded 
as  a  ship  disease,  or  rather  as  a  disease  developed  in  ship  from  germs 
taken  on  board  at  a  tropical  or  subtropical  port  or  elsewhere,  through 
the  medium  of  persons  coming  from  infected  or  endemic  districts,  and 
cultivated  by  the  artificial  conditions  of  the  forecastle. 

Eleven  cases,  occurring  among  foreign  seamen,  were  admitted  to 
the  Long  Island  College  Hospital  at  this  port  (New  York)  during 
the  year  1903,  and  the  records  of  the  U.  S.  Public  Health  and  Marine- 
Hospital  Service  for  the  last  ten  or  fifteen  years  show  that  sailors 
suffering  from  beriberi  have  been  admitted  to  marine  hospitals  at 
different  points  on  the  Atlantic  and  Pacific  coasts  of  the  United 
States  from  vessels  arriving  from  tropical  or  hot  countries.  The 
disease  is  frequently  carried  to  the  seaports  of  Great  Britain  by  vessels 
trading  to  India,  or  is  developed  en  route  because  of  the  peculiarly 
dirty  and  insanitary  condition  of  the  forecastle  and  its  occupants— 
the  lascars. 


30 

"  They  feel  the  cold  of  the  English  climate  so  much  that  on  enter- 
ing British  seas  they  try  to  keep  their  quarters  warm  by  lighting 
fires  and  stopping  up  all  ventilators.  By  these  means  they  create  a 
hot,  steamy,  atmosphere  and  a  sodden  state  of  the  place  they  live  and 
sleep  in,  which  is  a  very  good  imitation  of  the  tropical  conditions  the 
germ  of  beriberi  requires  for  its  development.  In  other  words,  those 
lascar  sailors  create  an  incubator  on  a  large  scale,  which,  should  it 
chance  to  contain  a  beriberi  germ,  quickly  becomes  extensively  in- 
fected and  lethal."  (Manson.) 

Four  forms  of  the  disease  are  recognized — 

(1)  The  mild  or  rudimentary  form  usually  begins  with  a  feeling 
of  weakness  and  numbness  of  the  extremities,  with  oedema  of  the 
shins  and  tenderness  of  the  muscles,  especially  of  the  calves,  uneasi- 
ness in  the  belly,  shortness  of  breath,  and  palpitation  of  the  heart. 
These  symptoms  may  last  only  a  few  days  or  several  weeks  and  then 
disappear,  but  recurrences  are  common. 

(2)  In  the  dry  or  atrophic  form  there  is  no  oedema,  but  the  other 
symptoms    are    marked    and    more    rapidly    developed.     Instead    of 
oedema  and  puffiness  there  is  atrophy  of  the  parts.     The  tendon  re- 
flexes are  lost.     The  legs  and  arms  and  sometimes  the  face  are  paral- 
yzed and  painful.     All  the  muscles  of  the  body  waste  away.     The 
patient  presents  a  pitiful,  shrunken  appearance,  suffers  intense  pain, 
is  sensitive  to  the  slightest  touch,  and  may  die  from  general  exhaus- 
tion  or.  after  lingering  many   months,  gradually   improve   and   get 
well. 

(3)  The  wet  or  dropsical  form  begins  with  symptoms  similar  to 
those  of  the  mild  form,  but  the  (edema  soon  extends  over  the  entire 
body,  watery  effusions  into  the  serous  sacs  take  place;  there  is  marked 
shortness  of   breath,   frequently    nausea    and    vomiting,   and   always 
weakness  of  the  heart.     Death  may  occur  from  heart  failure  or  from 
paralysis  of  respiration.     On  the  other  hand,  the  dropsy  may  grad- 
ually or  rapidly  disappear  and  leave  the  patient  in  essentially  the 
same  condition  as  that  described  under  the  head  of  the  dry  or  atrophic 
form. 

(4)  The  most  serious  or  dangerous  form  of  beriberi  is  called  the 
acute  pernicious  cardiac  form.     In  this  the  general  symptoms  of  the 
disease   may  be  only   slightly   developed,  but   the   cardiac    (heart) 
symptoms  are  marked.     The  disease  in  this  form  usually  lasts  several 
days  or  weeks,  but  death  may  occur  from  heart  failure  within  twenty- 
four  hours  from  the  onset. 

The  mortality  in  different  epidemics  varies  from  3  to  60  per  cent. 

Diagnosis. — In  tropical  regions  typical  cases  of  beriberi  are  easily 
recognized,  but  as  the  incubation  period  varies  from  several  weeks 
to  as  many  months  the  first  symptoms  of  the  disease  may  not  appear 
until  the  ship  is  far  away  from  the  tropical  country,  and  then  the 


31 

diagnosis  may  be  somewhat  difficult  for  the  reason  that  some  of  the 
symptoms  may  be  absent  or  those  present  so  slightly  developed  as  to 
be  easily  overlooked  until  the  man  suddenly  becomes  helpless  or  dies 
from  paralysis  of  the  heart.  Careful  examination  of  other  members 
of  the  crew  will  then  probably  show  symptoms  of  the  disease,  and  the 
captain  will  be  reminded  that  ship  beriberi  can  be  developed  only  in 
a  damp,  filthy,  ill-ventilated  or  overcrowded  forecastle,  into  which 
the  seed  (germ)  was  introduced  weeks  or  months  before.  Pain  and 
numbness  of  the  legs  and  palpitation  of  the  heart  occurring  in  men 
of  or  from  the  Tropics  should  suggest  the  possibility  of  the  presence 
of  beriberi,  and  also  the  necessity  for  prompt  action  on  the  part  of 
the  captain. 

Treatment. — "The  first  and  most  important  thing  to  be  attended 
to  in  the  treatment  of  a  case  of  beriberi  is  the  removal  of  the  patient 
from  the  building,  camp,  or  ship  in  which  the  disease  was  contracted." 
(Manson.) 

If  the  disease  breaks  out  during  the  voyage  all  the  men  must  be 
removed  from  the  forecastle  and  made  to  sleep  on  deck,  with  their 
bodies  properly  clothed  and.  if  necessary,  protected  by  an  awning. 

All  articles  of  clothing  and  bedding  should  be  boiled,  thoroughly 
washed,  and  dried  in  the  open  air.  The  forecastle  should  be  disin- 
fected by  burning  sulphur  (see  description  of  method,  p.  1(3), 
thoroughly  cleaned,  and  dried.  All  rotten  planking  and  bilge  water 
should  be  removed,  and  all  woodwork  should  -be  scraped  and  painted. 
No  one  should  be  allowed  to  sleep  in  the  forecastle  until  it  is  thor- 
oughly dried  and  aired;  overcrowding  must  he  avoided.  If  the  men 
have  been  eating  rice  in  any  quantity  it  should  be  stopped.  (In 
Japan  the  cause  of  the  disease  is  attributed  to  the  excessive  use  of 
rice  or  bad  rice  and  raw  or  spoiled  fish.)  Wheat  flour  and  oatmeal 
should  be  used  instead ;  also  beans  and  fat  meat,  fresh  meat,  milk  and 
eggs,  and  red  wine — all  in  liberal  quantities.  The  best  thing  the 
captain  can  do  for  the  sick  man  himself  (bearing  in  mind  the  possi- 
bility of  heart  failure  and  sudden  death),  is  to  relieve  him  from  duty 
and  allow  him  to  rest  in  bed;  or  if  not  too  sick,  move  about  slowly  in 
fresh  air  and  sunshine. 

In  the  beginning  of  the  disease,  especially  if  the  muscles  are  pain- 
ful, salicylate  of  soda,  1  gram  (15  grains)  three  or  four  times  a  day 
is  considered  good  treatment.  For  palpitation  or  irritability  of  the 
heart,  tincture  of  strophanthus,  5  drops  every  four  hours.  If  there 
are  marked  signs  of  heart  failure  inhalation  of  nitrite  of  amyl  may 
be  given — 3  or  1  drops  on  a  handkerchief  and  applied  to  the  nostrils. 

In  dropsical  cases  the  bowels  should  be  kept  open  by  the  use  of 
Epsom  or  Rochelle  salts,  a  tablespoon  fid  in  a  glass  of  water  two  or 
three  times  a  day. 


32 

In  the  atrophic  cases,  after  the  subsidence  of  the  pain,  rubbing  the 
muscles  (massage)  is  of  service. 

For  a  tonic  the  elixir  of  iron,  quinine,  and  strychnine  may  be  used 
to  advantage.  One  or  2  teaspoonfuls  three  times  a  day. 

DYSENTERY. 

Dysentery,  or  bloody  flux,  as  it  is  sometimes  called,  is  an  affection— 
an  inflammation  and  ulceratioii — of  the  mucous  membrane  of  the 
large  bowel.  It  occurs  in  different  degrees  of  severity.  It  may  be 
acute  or  chronic.  There  are  different  varieties.  Its  severest  form 
is  met  with  in  tropical  countries  where  it  frequently  occurs  in  wide- 
spread epidemics.  Epidemics  also  occur  in  temperate  regions.  Spo- 
radic cases  ma 3^  be  found  almost  everywhere.  The  disease  prevails 
in  summer  and  autumn.  It  may  attack  an  entire  ship's  crew. 

Bad  food,  unripe  fruit,  impure  drinking  water,  exposure  to  cold 
and  dampness,  while  probably  not  in  themselves  the  direct  cause  of 
dysentery,  doubtless  favor  the  operation  of  other  causes. 

/Symptoms. — The  onset  may  be  sudden  or  gradual.  There  may, 
or  may  not,  be  chills  or  chilliness.  There  is  usually  some  feverish- 
ness.  The  tongue  is  furred  and  moist,  but  soon  becomes  red  and  dry, 
or  brownish  and  glazed. 

The  first  stools  may  l>e  like  those  of  an  ordinary  diarrhea.  After 
jv  day  or  two,  or  maybe  within  a  few  hours,  these  are  replaced  by 
Miiall  mucous  stools  frequently  mixed  with  blood  and  small  particles 
of  fecal  matter.  Soon  the  evacuations  consist  of  mucus  alone,  or  of 
blood  and  mucus,  or  of  a  jelly-like  matter  and  small  white  clumps 
of  mucus.  Later  they  may  be  shreddy,  and  brownish  or  greenish  in 
color.  Patient  complains  of  cramps  and  "colicky"  pains  in  his 
belly;  a  burning  sensation  in  the  rectum,  with  a  feeling  as  if  some- 
thing must  be  expelled,  and  of  a  constant  desire  to  go  to  stool.  The 
evacuations  may  number  from  ten  to  twenty,  or  forty  to  fifty,  or 
even  a  hundred  or  more  a  day,  according  to  the  severity  of  the  case. 
The  quantity  of  each  may  not  exceed  a  teaspoonful. 

In  mild  cases  there  is  a  gradual  change  to  normal  and  patient  may 
recover  after  a  period  of  a  week  or  ten  days.  Severer  cases  continue 
for  several  weeks  or  longer,  and  then  recover,  or  become  chronic  and 
incurable,  or  death  may  occur  from  general  weakness. 

Tropical  dysentery,  the  variety  which  occurs  most  frequently  and 
in  epidemic  form  in  tropical  or  subtropical  regions,  but  also  occa- 
sionally in  temperate  climates,  is  said  to  be  produced  by  a  micro- 
organism wThich  enters  the  system  in  drinking  water. 

The  symptoms  in  this  form  of  dysentery  are  similar  to  those 
already  described.  The  burning  sensation  and  bearing-down  pain, 
however,  are  less  marked.  The  stools  are  less  frequent,  t>ut  they 


33 

are  larger  and  more  watery;  at  times  more  like  diarrhea  than 
typical  dysentery.  The  disease  in  favorable  cases  runs  a  course  of 
from  six  to  twelve  weeks.  Recovery  is  always  slow.  Death  may 
occur  from  exhaustion,  or  from  abscess  of  the  liver,  which  is  a 
common  complication.  In  the  most  fatal  epidemics  the  course  of 
the  disease  is  very  rapid.  Death  sometimes  occurs  within  a  few 
hours. 

Treatment. — Rest  in  bed.  If  possible,  the  patient  should  use  the 
bedpan  instead  of  the  commode  or  closet,  so  as  to  insure  the  greatest 
amount  of  rest,  which  is  very  important.  Stop  all  solid  food.  Give 
2  tablespoon fuls  (30  c.  c.)  of  castor  oil  and  15  drops  of  laudanum 
in  one  dose,  and  if  necessary  repeat  the  dose  in  six  hours,  or  give 
smaller  doses  at  intervals  of  four  hours.  After  the  bowels  have 
been  thoroughly  cleared  out,  a  pill  of  opium  (or  opium  and  camphor), 
or  opium  and  acetate  of  lead,  should  be  given  every  three  hours. 
Hot  applications  should  be  placed  on  the  abdomen.  The  bearing- 
down  pain  and  the  burning  sensation  may  be  relieved  by  washing 
out  the  rectum  with  a  pint  of  warm  water  and  by  injecting  2  ounces 
of  thin  starch  containing  25  or  30  drops  of  laudanum. 

In  place  of  the  castor  oil,  sulphate  of  magnesium  (Epsom  salts) 
may  be  given  in  tablespoonful  doses,  repeated  every  two  hours  until 
a  free  and  large  action  of  the  bowels  results,  and  then  the  pill  of 
opium,  or  opium  and  camphor,  or  opium  and  acetate  of  lead  given 
every  three  hours.  Or,  instead  of  the  opium  pills,  subnitrate  or 
subcarbonate  of  bismuth  may  be  given  in  30  or  40  grain  (2  gm.  or 
2.6  gm.)  doses. 

After  two  or  three  days,  if  the  disease  continues,  the  castor  oil 
or  the  Epsom  salts  may  be  repeated,  and  after  its  effect  is  pro- 
duced, the  same  line  of  treatment  continued. 

Or,  in  place  of  the  oil  and  salts,  5  grains  (0.33  gm.)  of  calomel 
may  be  given,  and  repeated,  if  necessary,  in  six  hours. 

The  diet  should  be  limited  to  the  lightest  articles,  such  as  thin 
porridge,  milk,  and  broths.  And  even  in  the  lightest  cases  the  patient 
should  be  kept  warm  in  bed. 

In  tropical  countries,  or  in  the  treatment  of  tropical  dysentery, 
the  remedy  chiefly  relied  on  is  powdered  ipecac.  The  patient  is 
not  allowed  any  food  for  three  or  four  hours,  then  he  is  given  15 
drops  of  laudanum,  and  this  is  followed  in  twenty  minutes  by  a 
dose  of  from  20  to  60  grains  (1.33  gm.  to  4  gm.)  of  ipecac.  To  pre- 
vent vomiting  the  patient  is  placed  flat  on  his  back  and  kept  very 
quiet  for  three  or  four  hours.  If  vomiting  occurs  within  an  hour, 
the  dose  is  repeated. 

The  best  means  of  protection  or  prevention  is  to  keep  the  body 
in  sound  condition.  If  the  disease  occurs  among  the  ship's  crew, 

13256—04  M 3 


34 

the  healthy  men  should  be  very  careful  not  to  catch  cold,  and  to 
avoid  errors  in  eating  and  drinking.  Sudden  changes  of  tempera- 
ture should  be  guarded  against  by  a  proper  supply  of  clothing. 
The  drinking  water  should  be  boiled. 

SUNSTROKE. 

The  term  sunstroke  denotes  a  sudden  attack  of  illness  from  expos- 
ure or  prolonged  exposure  to  the  rays  of  the  sun;  but  the  same 
condition  may  be  produced  in  hot  weather  by  exposure  to  high 
temperature  not  in  the  direct  rays  of  the  sun,  particularly  if  the 
person  is  engaged  at  hard  work  in  close  quarters.  Stokers  on 
steamships  are  sometimes  affected  by  the  heat  of  the  furnace.  Men 

debilitated  from  or  addicted  to  the  excessive  use  of  stimulants  are 

- 

more  apt  to  suffer  than  those  of  temperate  habits. 

Sunstroke  occurs  in  two  forms :  Heat  stroke  (heat  fever) ,  in  which 
the  temperature  of  the  body  is  very  high,  and  heat  prostration  or 
heat  exhaustion,  in  which  the  surface  of  the  body  is  cool,  sometimes 
considerably  below  normal.  The  difference  is  very  important  because 
of  the  different  treatment  required. 

In  severe  cases  of  heat  stroke,  the  patient  may  be  stricken  down 
in  a  state  of  unconsciousness  and  die  instantly  or  within  an  hour  or 
two.  In  other  cases  there  may  be  intense  headache,  dizziness,  marked 
restlessness,  nausea  and  vomiting  and  hot  "  burning "  skin.  The 
thermometer  may  register  110°  F.  (43.3°  C.).  Pulse  is  full  and  may 
be  slow  or  fast.  Breathing  is  labored,  may  be  sighing  or  rattling. 
Patient  soon  becomes  unconscious,  the  stupor  deepens  and  death 
may  occur  within  twenty-four  hours;  or  the  temperature  may  drop, 
consciousness  may  return  and  the  patient  get  well. 

In  heat  prostration,  as  already  stated,  the  surface  of  the  body  is 
cool,  the  pulse  rapid  and  feeble,  and  there  is  a  feeling  of  general 
weakness.  There  may  be  only  slight  f  aintness  and  nausea,  and  under 
prompt  treatment  patient  may  rapidly  recover,  or,  on  the  other  hand, 
there  may  be  complete  loss  of  consciousness  and  a  rapid  and  fatal 
termination  from  exhaustion  and  heart  failure. 

Treatment. — In  heat  stroke  (heat  fever)  the  temperature  of  the 
body  should  be  reduced  as  rapidly  as  possible.  Remove  the  patient 
to  the  coolest  and  best  ventilated  part  of  the  ship.  Place  him  in  a 
cold-water  bath,  add  ice,  rub  the  body  with  the  blocks  of  ice,  apply 
iced  water  with  ice  cap  to  his  head ;  and  keep  up  the  treatment 
until  the  temperature,  as  shown  by  the  thermometer  in  the  rectum 
is  reduced  to  100°  F.  (37.7°  C.).  If  the  temperature  rise  again, 
repeat  the  treatment.  If  symptoms  of  exhaustion  follow  the  reduc- 
tion of  the  temperature,  stimulants  should  be  given — whisky  or 
brandy  and  water  in  small  quantities. 

In  heat  prostration,  with  cool  skin,  weak  and  rapid  pulse,  stimu.- 


35 

hints  and  friction  are  required.  Give  brandy  or  whisky,  rub  the 
surface  of  the  body  and  the  extremities,  place  hot  water  bottles  to 
the  feet,  and  cover  the  body  with  blankets.  If  the  head  is  hot, 
apply  cold  water  to  the  forehead.  If  vomiting  occur,  inject  the 
stimulants  into  the  rectum.  Apply  mustard  over  the  region  of  the 
stomach.  Mustard  may  also  be  applied  to  the  feet. 

DIARRHEA. 

Acute  diarrhea  is  caused  by  acute  inflammation  or  by  irritation  of 
the  intestines.  It  may  occur  as  a  complication  in  many  different 
diseases.  It  is  usually  one  of  the  symptoms  of  typhoid  fever.  It  is 
not  infrequently  met  with  in  severe  cases  of  malaria.  It  is  called 
functional  or  simple  diarrhea  when  it  occurs  independently  of  any 
other  appreciable  disease.  It  may  be  caused  by  exposure  to  cold  or 
by  errors  in  diet.  Diarrhea,  or  looseness  of  the  bowels,  is  sometimes 
produced  by  the  receipt  of  unexpected  and  exciting  news,  by  a  sudden 
fright,  or  by  any  strong  mental  emotion;  intestinal  digestion  is 
arrested  and  diarrhea  is  the  result. 

In  simple  diarrhea  there  may  or  may  not  be  griping  and  colicky 
pains.  In  the  more  severe  forms  the  tongue  is  coated  and  there  is 
some  fever.  Thirst  is  marked  in  proportion  to  the  size  and  frequency 
of  the  thin  or  watery  discharges.  If  the  rectum  is  affected,  there  is  a 
constant  desire  to  go  to  stool,  and  a  burning  sensation  and  bearing- 
down  pain,  as  in  dysentery. 

Diarrhea  may  last  from  a  few  hours  to  as  many  days,  or  longer.  It 
may  become  chronic. 

Treatment. — In  all  cases,  rest  and  light  diet.  In  the  milder  forms 
nothing  further  may  be  required.  In  the  more  severe  forms  it  is 
a  good  plan  to  begin  with  a  dose  of  1  or  2  tablespoonfuls  of  castor  oil, 
to  which  10  or  12  drops  of  laudanum  may  be  added,  or  in  place  of  the 
oil  and  laudanum  Epsom  salts  or  Rochelle  salts  may  be  given.  The 
diet  should  be  limited  to  light  articles,  such  as  cornstarch,  gruel,  weak 
broths,  soft-boiled  eggs,  milk,  and  thoroughly  toasted  bread.  As  a 
rule,  in  very  acute  cases,  the  less  food  and  drink  taken  the  better. 
The  patient  should  rest  in  bed  and  keep  his  body  warm. 

After  the  bowels  have  been  freely  moved  by  the  oil  or  salts,  if  the 
diarrhea  or  pain  continue,  give  2  tea  spoonfuls  of  equal  parts  of  pare- 
goric and  tincture  of  catechu,  and,  if  necessary,  repeat  the  dose  after 
an  interval  of  three  or  four  hours.  If  nausea  and  vomiting  occur, 
apply  mustard  to  the  region  of  the  stomach,  and  give  tablespoonful 
doses  of  equal  parts  of  milk  and  lime  water,  or  a  little  champagne  and 
carbonated  water. 

In  chronic  diarrhea  careful  attention  to  diet  is  of  the  greatest  im- 
portance. The  treatment  is  about  the  same  as  for  chronic  dysentery. 


36 

CHOLERA  MORBUS   (SPORADIC  CHOLERA). 

Cholera  niorbus  is  an  affection  of  the  stomach  and  intestines, 
attended  by  vomiting,  purging,  and  cramps.  It  comes  on  suddenly, 
and  may  begin  by  vomiting  or  purging.  It  is  usually  met  with  dur- 
ing the  hot  months  of  summer.  It  is  frequently  caused  by  eating 
unripe  and  indigestible  fruits  and  vegetables  or  decomposed  or 
improperly  cooked  fish  or  shell  fish,  or  salad  mixtures.  Drinking 
large  quantities^  of  iced  water  and  sudden  checking  of  the  perspira- 
tion, or  irritants  of  any  kind,  may  set  up  the  trouble.  The  disease 
usually  begins  suddenly,  often  at  night,  with  vomiting,  or  after  a 
feeling  of  uneasiness  or  nausea  or  a  severe  cramp.  The  contents  of 
the  stomach  are  first  thrown  up,  then  a  slimy  bilious  matter,  and  later 
the  vomited  matter  seems  to  be  pure  water.  The  stools  are  at  first 
solid  or  semisolid,  but  they  soon  become  more  watery,  lose  their  color, 
and  sometimes  appear  not  unlike  the  rice-water  stools  of  genuine 
Asiatic  cholera.  The  patient  soon  has  a  wasted  look.  His  thirst 
is  unquenchable.  His  skin  may  become  cold  and  clammy  and  the 
pulse  very  weak.  Cramps  may  occur  in  the  feet  and  in  the  calves 
of  the  legs.  The  disease  runs  a  rapid  course.  The  acute  symptoms 
may  subside  in  a  few  hours.  The  attack  seldom  lasts  more  than 
twelve  hours.  Recovery  is  the  rule,  but  treatment  should  be  promptly 
applied. 

Treatment. — Apply  a  large  mustard  plaster  to  the  abdomen.  Give 
15  drops  of  tincture  of  opium  (laudanum).  If  the  dose  is  rejected 
(immediately  vomited),  try  it  again.  If  rejected  a  second  time, 
then  a  morphine  pill  or  tablet  ^  grain  (0.01  gin.)  should  be  given 
If  the  morqhine  pill  is  quickly  rejected,  it  may  be  tried  a  second  time 
by  crushing  or  rubbing  it  into  a  powder  and  placing  it  on  the  back 
of  the  patient's  tongue  immediately  after  an  act  of  vomiting.  If 
the  laudanum  or  morphia  are  not  retained,  then  try  a  teaspoonful  of 
"  hot  drops,"  or  a  teaspoonful  of  "  Sun  Cholera  Mixture."  If  vom- 
iting quickly  occur,  then  inject  into  the  rectum  by  means  of  a  glass 
or  rubber  syringe  about  40  drops  of  laudanum  mixed  with  a  little 
thin  starch  or  a  little  water.  The  rectal  injection  should  be  given 
immediately  after  an  evacuation,  and  the  patient  should  be  instructed 
to  hold  it  as  long  as  possible.  In  whatever  way  the  remedy  is  given 
the  dose  should  be  repeated  in  about  one  hour  if  the  vomiting  and 
purging  continue. 

It  must  not  be  forgotten,  however,  that  all  these  remedies  contain 
opium  and  that  if  the  patient  is  inclined  to  sleep  or  shows  other  con- 
stitutional effect  of  the  drug  the  dose  must  not  be  repeated. 

The  nausea  and  thirst  may  be  controlled  by  cracked  ice  placed  in 
the  mouth.  Small  quantities  of  carbonated  water,  or  of  iced  cham- 
pagne, may  be  allowed.  If  the  thirst  is  very  urgent,  a  tablespoonful 


37 

of  iced  water  may  be  given  at  short  intervals.  Large  quantities  of 
water  must  not  be  allowed.  If  there  is  marked  prostration,  a  little 
brandy  and  water  or  whisky  and  water  should  be  given. 

COLIC. 

Intestinal  or  spasmodic  colic. — These  terms  are  applied  to  abdom- 
inal pain  occurring  in  paroxysms  of  different  degrees  of  severity. 
The  pain  is  usually  referred  to  the  region  of  the  navel  or  middle 
of  the  belly.  It  may  be  due  to  indigestible  food,  cold  or  acid  drinks, 
poisons,  gases,  or  any  irritating  substance.  It  is  often  preceded  by 
obstinate  constipation.  Vomiting  frequently  occurs,  and  in  malarious 
districts  it  is  apt  to  be  "  bilious." 

Foods  and  drinks  taken  in  excessive  quantity  are  frequently  the 
cause  of  indigestion. 

Another  variety  of  colic,  called  lead  colic  or  painters  colic,  is 
caused  by  lead  poisoning.  It  is  not  .uncommon  in  painters  or  work- 
ers in  lead.  It  may  be  caused  by  drinking  water  taken  from  leaden 
pipes.  An  attack  may  be  mild  or  exceedingly  severe.  It  is  usually 
attended  by  obstinate  constipation  and  by  contraction  of  the  abdo- 
men. 

The  severe  paroxysmal  pain  attending  the  passage  of  a  gallstone 
from  the  gall  bladder  to  the  intestine  is  called  biliary  colic.  In 
biliary  colic  the  pain  is  usually  most  marked  in  the  region  above  the 
navel  or  about  the  stomach  (epigastric  region).  The  paroxysms 
begin  and  end  suddenly.  Severe  nausea  and  vomiting  occur.  The 
skin  and  eyes  may  become  yellow  or  of  a  yellowish  hue  (jaundiced), 
the  same  as  in  bilious  colic.  Gallstones  may  occasionally  be  found 
in  the  stools  if  carefully  looked  for.  Some  cases,  however,  are 
difficult  to  distinguish  from  ordinary  intestinal  colic. 

The  severe  excruciating  pain  caused  by  the  passage  of  a  small 
rough  stone  or  calculus  or*  particles  of  sandy  substance  from  the 
kidney  through  the  ureter  to  the  urinary  bladder  is  called  nephritic 
colic,  kidney  colic,  or  an  attack  of  "  the  gravel."  The  pain  usually 
begins  with  a  one-sided  boring  backache.  Suddenly  it  increases  in 
intensity  and  shoots  down  the  loin  to  the  hip  and  thigh,  and  the 
patient  writhes  in  agony  until  the  "  stone  "  or  particle,  sometimes 
not  larger  than  the  head  of  a  medium-sized  pin,  reaches  the  bladder, 
when  the  pain  suddenly  ceases.  The  paroxysm  may  last  from  half 
an  hour  to  a  number  of  hours,  or  one  or  two  days.  It  may  not  recur 
for  months  or  years;  on  the  other  hand  there  may  be  two  or  more 
paroxysms  at  comparatively  short  intervals. 

Colicky  pains  are  present  in  many  different  diseases.  Appendicitis 
frequently  begins  with  pain  not  unlike  that  of  intestinal  colic. 

Treatment. — If  the  colic  is  due  to  indigestible  food,  or  too  much 
food  of  any  kind,  an  emetic  should  be  given. 


38 

After  the  stomach  is  emptied  give  a  little  spirit  (brandy  or  whisky) 
with  10  or  15  drops  of  tincture  or  essence  of  ginger  or  essence  of  pep- 
permint, diluted  with  hot  water.  Apply  a  large  mustard  plaster  or  a 
hot  poultice  or  cloths  wrung  out  of  hot  water,  or  heat  of  any  kind  to 
the  abdomen.  (Local  applications  of  hot  water  usually  afford  some 
relief  in  any  variety  of  colic  or  wherever  pain  exists.)  If  the  colicky 
pains  persist,  10  or  12  drops  of  laudanum  should  be  given  by  the 
mouth  or  a  pill  of  morphine,  grain  (0.01  gm.) ,  and  repeated,  if  neces- 
sary, in  two  hours ;  or  30  or  40  drops  of  laudanum  in  a  little  water  or 
starch  may  be  injected  into  the  rectum. 

If  the  bowels  were  constipated  when  the  attack  began,  an  injection 
of  soap  and  warm  water  should  be  given  by  the  rectum,  or  small  doses 
of  Epsom  salts  or  castor  oil  may  be  given  by  the  mouth.  The  diet 
for  a  day  or  two  should  be  light  articles  in  small  quantities  at  a  time. 
The  treatment  for  lead  colic  is  about  the  same,  except  that  the  consti- 
pation should  be  relieved  at  once  by  full  doses  of  Epsom  salts  or  castor 
oil.  Apply  heat  to  the  abdomen  or  place  the  patient  in  a  warm  bath. 
Pressure  applied  to  the  abdomen  affords  some  relief.  Remove  the 
cause  or  remove  the  patient  from  the  cause  of  the  disease. 

In  biliary  colic,  the  bowels  should  be  freely  moved,  patient  should 
be  placed  in  a  hot  bath,  and  laudanum  or  morphia  given  to  relieve 
pain. 

In  nephritic  or  kidney  colic,  hot  baths  and  morphia  are  the  reme- 
dies. A  morphine  pill,  J  grain  (0.01  gm.),  should  be  given,  and 
repeated  in  one  hour  if  the  pain  is  not  relieved,  and  the  bath  should 
be  as  hot  as  the  patient  can  stand  it.  The  best  method  of  giving 
morphia  in  all  cases  of  severe  pain  is  by  hypodermic  injection  (injec- 
tion under  the  skin),  and  in  many  cases  where  the  stomach  is  irritable 
and  vomiting  occurs  this  is  the  only  way  to  obtain  the  desired  effect. 
But  hypodermic  medication  by  inexperienced  persons  is  not  to  be 
recommended.  » 

SCURVY. 

Scurvy  is  a  disease  produced  by  improper  or  unsuitable  food. 
Many  years  ago  it  was  of  frequent  occurrence  among  seafaring  men 
on  long  voyages.  Now  it  is  a  comparatively  rare  disease,  thanks  to 
better  provisions  and  better  methods  in  issuing  food  supplies.  Occa- 
sionally, however,  a  ship  comes  in  with  scurvy  on  board.  Two  years 
ago  twelve  cases  were  admitted  to  the  U.  S.  Marine  Hospital  at  New 
York  from  one  vessel. 

Symptoms. — Swelling,  sponginess,  and  bleeding  of  the  gums.  The 
teeth  become  loose  and  frequently  drop  out.  The  breath  is  foul,  the 
tongue  swollen.  The  skin  becomes  dry  and  scaly.  Hemorrhages 
(small  dark  red  spots)  dccur  under  the  skin,  first  on  the  legs  and  then 
on  the  arms  and  other  parts  of  the  body.  Bleeding  frflm  the  nose 


39 

frequently  occurs.  Swelling  about  the  ankles  is  common.  The  skin 
of  the  legs  is  frequently  discolored  in  large  blotches,  and  there  is  often 
a  peculiar  hardness  or  induration  of  the  muscles  of  the  calf  of  the 
leg.  The  complexion  is  frequently  of  greenish  or  dirty-yellow  hue. 
The  pulse  is  rapid  and  weak.  There  may  or  may  not  be  slight 
fever.  The  bowels  may  be  constipated  or  there  may  be  a  troublesome 
diarrhea. 

In  severe  cases  debility  and  emaciation  are  quite  marked.  The 
mind  wanders,  and  occasionally  there  is  wild  delirium. 

Treatment. — This  consists  almost  wholly  in  a  change  of  diet.  Give 
fresh  vegetables,  fresh  milk,  fresh  beef,  oranges,  lemons,  limes,  or 
lime  juice.  Begin  with  small  quantities  at  short  intervals,  and 
increase  the  allowance  as  rapidly  as  the  stomach  can  take  care  of  it. 
Pickles,  onions,  sauerkraut,  raw  potatoes,  and  raw  cabbage  are  valu- 
able articles  in  the  make-up  of  a  varied  diet. 

Chlorate  of  potassium  dissolved  in  water  should  be  used  as  a  mouth 
wash,  and  the  gums  should  be  frequently  painted  with  tincture  of 
myrrh.  The  skin  should  be  kept  in  good  condition  by  frequent  bath- 
ing. The  sleeping  quarters  should  be  clean  and  well  ventilated. 

SORE   THROAT    (TONSILITIS,   QUINSY). 

Sore  throat  is  a  common  disease.  It  is  usually  the  result  of  expos- 
ure to  wet  and  cold.  Talking,  laughing,  or  shouting  in  a  damp, 
cold  atmosphere  is  sometimes  the  cause  of  it.  It  frequently  occurs 
in  persons  predisposed  to  rheumatism.  It  may  accompany  or  be 
an  extension  from  an  ordinary  "  cold  in  the  head."  Sometimes 
the  inflammation  is  limited  to  the  mucous  membrane  of  the  pharynx 
and  soft  palate;  it  is  then  known  as  pharyngitis  or  acute  catarrhal 
sore  throat.  More  frequently  the  tonsils  are  affected,  and  the  inflam- 
mation is  then  called  tonsilitis.  When  the  inflammation  is  more 
deeply  seated  in  the  tonsil  and  tends  to  suppurate  or  form  an 
abscess  the  term  quinsy  is  applied.  An  attack  of  sore  throat  may 
last  from  two  to  ten  days,  or  longer. 

Symptoms  of  acute  sore  throat  are  chilliness  and  feverishness, 
pain  or  soreness  on  swallowing,  dryness,  or  a  tickling  or  scratching 
sensation  in  the  throat. 

There  is  apt  to  be  a  stiffness  and  some  tenderness  along  the  side  of 
the  neck.  If  one  or  both  tonsils  are  involved,  as  they  usually  are 
to  a  greater  or  less  extent,  the  symptoms  are  more  severe.  In  marked 
cases  examination  shows  redness  and  swelling  of  the  parts  affected- 
swollen  tonsils  (tonsilitis)  and  white  or  cream-colored  spots  may  be 
seen  on  the  surface  of  one  or  both  tonsils.  (This  form  of  the  disease 
is  frequently  mistaken  for  diphtheria.)  There  may  be  high  fever  and 
great  prostration. 

In  the  severest  form  of  tonsilitis   (quinsy)    the  tonsils  are  hard 


40 

and  swollen  to  twice  or  three  times  their  natural  size,  and  the  patient 
is  unable  to  swallow  or  to  open  his  mouth  beyond  a  fraction  of  an 
inch.  The  saliva  dribbles  away;  if  suppuration  occur  the  tonsil 
gradually  softens  until  the  abscess  breaks.  With  the  discharge  of 
the  pus  the  severe  pain  is  relieved  and  the  patient  rapidly  recovers. 
If  the  abscess  is  large,  and  if  the  pus  is  discharged  in  a  backward 
direction,  there  is  danger  from  suffocation,  particularly  if  the  abscess 
breaks  during  sleep.  Fortunately  the  abscess  usually  points  toward 
the  mouth,  and  the  pus  runs  out. 

Treatment. — Persons  who  are  subject  to  attacks  of  sore  throat 
should  keep  their  feet  clean  and  dry  and  be  very  careful  not  to  catch 
cold.  If  a  case  develop,  give  a  gargle  of  salt  water  or  chlorate  of 
potassium  and  water  (saturated  solution)  or  borax  and  water,  or  dry 
borax  may  be  applied  to  the  tonsil.  Dry  bicarbonate  of  sodium  (bak- 
ing soda)  is  highly  recommended  as  a  local  application,  a  small  quan- 
tity to  be  applied  every  hour.  Apply  cold  water  or  a  light  ice  bag  to 
the  neck,  or  a  thick  piece  of  flannel  saturated  w7ith  ice  water  may  be 
placed  around  the  neck  and  covered  with  oiled  silk  or  oiled  muslin. 
Small  pieces  of  ice  placed  in  the  mouth  are  usually  agreeable.  The 
bowels  should  be  kept  open  by  means  of  Epsom  or  Rochelle  salts. 
If  the  fever  is  high  and  the  pulse  full,  give  one  drop  of  tincture  of 
aconite  in  a  teaspoonf  ul  of  water  every  hour.  Give  a  Dover's  powder 
at  night. 

If  the  cold  applications  to  the  neck  do  not  give  relief,  or  if  they  are 
not  agreeable  to  the  patient,  apply  hot  water  or  poultices  and  give 
hot  gargles,  or  let  the  patient  gargle  with  hot  tea.  If  the  swelling 
is  very  great,  he  can  not  gargle.  If  near  port,  send  for  a  surgeon. 

When  the  swelling  and  acute  symptoms  begin  to  subside  give  5 
drops  of  the  tincture  of  chloride  of  iron  with  20  drops  of  glycerine  in 
a  teaspoonful  of  water  every  two  hours.  The  diet  should  be  liquid 
or  soft,  and  nourishing. 

ERYSIPELAS    (ST.  ANTHONY'S    FIRE). 

Erysipelas  is  an  inflammation  of  the  skin.  It  usually  begins  with 
a  chill,  followed  by  a  high  fever.  It  is  a  frequent  complication  of 
wounds,  but  is  more  frequently  developed  without  any  apparent 
injury.  A  large  majority  of  cases  begin  on  the  face,  usually  on 
the  nose,  first  as  a  small  red  spot,  which  is  soon  elevated  above  the 
surrounding  skin,  and  gradually  or  rapidly  spreads  over  the  face 
and  ears,  and  not  infrequently  over  the  entire  hairy  scalp;  some- 
times over  the  neck  and  chest,  and  occasionally  down  the  back  and 
to  other  parts  of  the  body.  The  skin  is  painful,  red,  hot,  and  swollen, 
and  blisters  frequently  form.  The  swelling  is  most  marked  about 
the  eyes  and  ears,  the  eyes  are  closed,  and  the  patient's  features  are 
changed  and  distorted  to  such  a  degree  that  the  appearance  once  sean 


41 

will  not  soon  be  forgotten.  The  disease  limited  to  the  face  and  scalp 
usually  runs  its  course  in  a  few  days  or  a  week,  but  sometimes  before 
the  face  is  healed  red  spots  appear  on  other  parts  of  the  body,  and  the 
case  may  be  prolonged.  Abscesses  beneath  the  skin  are  not  uncommon. 

Besides  the  symptoms  already  mentioned  there  are  headache,  loss 
of  appetite,  coated  tongue,  frequently  vomiting,  and  in  some  cases 
delirium  and  marked  depression. 

The  outcome  is  usually  favorable,  but  in  drunkards  or  in  persons 
debilitated  from  previous  diseases  death  is  sometimes  the  result. 

Treatment. — Erysipelas  is  only  slightly  contagious,  under  ordinary 
circumstances;  but  persons  suffering  from  wounds  or  scratches  of 
the  skin  are  very  apt  to  be  attacked.  The  patient  should  therefore  be 
isolated — placed  in  a  room  by  himself — and  his  attendant  should  be  a 
healthy  man  and  free  from  any  skin  injury. 

Erysipelas  being  a  self-limited  disease,  it  is  a  common  saying 
among  physicians  that  the  majority  of  ordinary  or  moderately  severe 
cases  would  get  well  without  any  treatment.  But  this  is  probably 
true  of  many  other  diseases,  and  while  it  may  be  difficult,  perhaps 
impossible,  to  limit  the  spread  of  the  eruption  or  shorten  the  course 
of  the  disease  in  a  given  case  of  erysipelas,  something  may  be  done  to 
relieve  distressing  symptoms  and,  particularly  in  feeble  persons,  to 
fortify  the  system  against  the  attack.  "  Treat  the  patient  rather 
than  the  disease  "  is  good  advice  in  more  troubles  than  one. 

The  oldest  and  one  of  the  best  local  applications  for  erysipelas  is 
cold  water,  and  if  the  fever  is  very  high  cold  sponging  of  the  entire 
body  or  a  cold  bath  may  afford  considerable  relief.  Subnitrate  or 
subcarbonate  of  bismuth  may  be  dusted  over,  or  vaseline  may  be 
applied  to  the  skin.  In  feeble  persons  stimulants  are  required,  and 
for  the  restlessness  or  sleeplessness  a  pill  of  morphine  sulphate,  J 
grain  (0.01  gm.) ,  or  12  drops  of  laudanum  may  be  given  and  repeated, 
if  necessary,  in  two  hours.  *  The  tincture  of  the  chloride  of  iron  has 
been  a  popular  remedy  for  a  long  time,  and  if  given  in  moderate  doses 
of  10  or  12  drops  in  water  every  three  hours  may  do  a  great  deal  of 
good.  Epsom  or  Kochelle  salts  may  be  given  to  keep  the  bowels  open. 

RHEUMATISM. 

There  are  different  forms  of  rheumatism  and  some  of  the  forms 
have  several  different  names.  Acute  rheumatism,  acute  articular 
rheumatism,  inflammatory  rheumatism,  and  rheumatic  fever  are 
terms  applied  to  one  and  the  same  disease.  A  milder  form  of  the 
affection  is  called  subacute  rheumatism.  In  this  form  the  symptoms 
are  less  severe,  but  the  disease  is  more  prolonged.  It  may  continue 
for  a  long  time  and  become  chronic.  Chronic  rheumatism,  however, 
or  the  different  affections  and  deformities  of  joints  to  which  this 


42 

term  is  frequently  applied  may  develop  independently  of  any  acute 
or  subacute  attack. 

The  term  muscular  rheumatism  indicates  an  affection  of  the  mus- 
cles as  distinguished  from  joint  affections.  Lumbago  and  stiff  neck 
are  varieties  of  muscular  rheumatism.  The  muscles,  however,  to 
a  greater  or  less  extent  may  be  involved  in  any  form  of  rheumatism. 

Other  conditions  simulating  rheumatism,  occuring  in  connection 
with,  or  directly  due  to  gonorrhea,  or  to  syphilis,  are  called  gonor- 
rheal  rheumatism  or  syphilitic  rheumatism,  as  the  case  may  be. 

Acute  rheumatism  (rheumatic  fever)  is  a  comparatively  common 
disease  in  all  climates  within  the  temperate  zone.  It  occurs  chiefly 
during  the  winter  and  spring.  Exposure  to  a  cold,  damp  atmosphere 
is  the  most  frequent  exciting  cause  in  persons  predisposed  to  the 
disease. 

It  may  or  may  not  begin  with  a  chill  or  with  a  sore  throat.  The 
larger  joints  are  usually  affected.  Swelling,  heat,  redness,  tenderness ; 
and  pain  are  the  chief  symptoms.  The  inflammation  is  apt  to  shift 
from  one  joint  to  another.  The  pain  and  fever  are  usually  increased 
in  proportion  to  the  number  of  joints  involved.  The  majority  of 
cases  are  attended  with  profuse  perspirations,  scanty,  highly  acid 
urine,  coated  tongue,  and  constipation.  The  heart  is  frequently 
involved. 

Treatment. — Wrap  the  joint  in  cotton  or  flannel;  keep  them  very 
quiet — the  slightest  movement  aggravates  the  pain.  Flannel  wrung 
out  of  hot  water  and  applied  to  the  joint  sometimes  affords  relief. 
Chloroform  liniment  may  be  applied  if  the  pain  is  severe,  or  cold 
applications  may  be  Applied  if  agreeable  to  the  patient. 

Place  the  patient  in  a  good  bed,  between  blankets,  and  let  him  wear 
flannel  next  to  his  skin.  Change  the  flannel  frequently  and  bathe 
the  body  with  tepid  water. 

For  internal  medication  give  salicylate'of  sodium  in  doses  of  10  to 
15  grains  (0^6  gm.  to  1  gin.)  every  two  hours  until  about  eight  doses 
are  taken  or  the  pain  is  relieved,  then  give  it  in  smaller  doses  of 
from  3  to  5  grains  (0.2  gm.  to  0.3  gm.)  every  six  hours.  Dover's 
powder  may  be  given  at  night  to  control  pain  and  restlessness. 
Patient  may  be  allowed  to  drink  lemonade  or  pure  water  to  satisfy 
his  thirst. 

The  food  should  be  soft  and  nourishing  and  given  every  three 
hours.  Epsom  or  llochelle  sajts  should  be  given  to  keep  the  bowels 
open.  The  patient  should  be  kept  in  bed  for  a  few  days  after  the 
symptoms  have  subsided.  The  duration  of  the  disease  is  very  uncer- 
tain. The  acute  symptoms  may  subside  in  a  few  days  and  the  patient 
may  be  up  and  about  in  a  week  or  ten  days,  but  relapses  are  common 
and  the  acute  may  pass  into  the  subacute  or  chronic  form. 

In  chronic  rheumatism  there  is  stiffness  and  pain.     A  cracking  or 


43 

grating  sound  is  frequently  produced  when  the  joints  are  suddenly 
moved.  In  severe  cases  the  joints  become  enlarged  and  distorted. 
The  deformity  is  sometimes  very  great. 

The  treatment  consists  chiefly  in  local  application  of  liniments, 
etc.,  which  afford  relief  because  of  the  rubbing  (massage)  by  which 
they  are  applied.  Severe  pain  in  the  joint  may  be  relieved  by  cold 
applications  (flannel  wrung  out  of  iced  water,  applied  to  the  joint 
and  covered  with  oiled  silk  or  oiled  muslin).  Hot  aplications  to  the 
joints  are  sometimes  of  value. 

Five  to  eight  grains  (0.3  gin.  to  0.5  gm.)  of  iodide  of  potassium 
in  a  teaspoonful  of  sirup  of  sarsaparilla  and  a  little  water,  or  in 
water  alone,  may  be  given  three  times  a  day  after  meals. 

The  general  health  should  be  looked  after.  The  skin  should  be 
kept  in  good  condition  by  frequent  baths  of  tepid  water.  The 
bowels  should  be  moved  at  least  once  a  day.  Patient  should  be 
allowed  good  food.  Fresh  air  is  also  important. 

In  muscular  rheumatism  the  muscles  most  frequently  affected 
are  those  of  the  back  (lumbago),  side  of  neck  (stiff  neck  or  wry 
neck),  and  side  of  chest  (pleurodynia).  Exposure  to  cold,  sudden 
cooling  of  the  body — especially  after  active  exercise,  and  sitting  in 
a  draft  of  air — are  the  chief  causes,  or  exciting  causes. 

As  a  rule  there  are  no  symptoms  other  than  the  stiffness  and  pain 
on  motion.  The  muscles  may  be  slightly  swollen,  and  very  sensi- 
tive. Sometimes  the  attacks  come  on  suddenly  and  apparently  with- 
out cause,  or  following  a  slight  twist  or  strain,  as  a  "  kink  in  the 
back,"  or  patient  may  wake  up  in  the  morning  with  a  stiff  neck. 

Treatment. — In  acute  cases  salicylate  soda  may  be  given  in  5  or 
10-grain  doses  (0.3  gm.  to  0.6  gm.)  every  three  hours  until  four  or 
six  doses  are  taken.  Apply  hot  applications,  dry  heat,  hot-water 
bag,  or  a  hot  poultice  locally,  or  the  heat  may  be  applied  by  a  flat- 
iron,  over  folds  o'f  flannel  or  a  piece  of  blanket,  and  the  rheumatism 
u  ironed  out."  Later  apply  liniment  with  friction  (massage).  Keep 
the  affected  muscles  at  rest.  If  the  muscles  of  the  chest  are  affected, 
apply  strips  of  adhesive  plaster,  the  same  as  for  fractured  rib.  Acute 
attacks  are  of  short  duration,  but  relapses  are  not  uncommon,  and 
chronic  forms  are  frequently  met  with.  Good  food,  fresh  air,  arid 
attention  to  the  general  health  are  especially  important  in  the  treat- 
ment of  chronic  muscular  rheumatism. 

Gonorrheal  rheumatism,  (gonorrheal  inflammation  of  joints)  may 
occur  during  an  acute  attack  or  gonorrhea,  but  it  is  more  frequently 
associated  with  chronic  gonorrhea  or  gleet.  One  or  several  joints 
may  be  affected.  There  may  or  may  not  be  considerable  fever.  If 
only  one  joint  is  affected  it  is  apt  to  be  the  knee  or  the  ankle.  In 
chronic  cases  the  pain  is  sometimes  centered  in  the  heel.  The  attack 
may  begin  in  the  wrist,  elbow,  or  shoulder.  The  disease  is  not  always 


44 

limited  to  the  joints.  Sometimes  the  inflammation  is  in  the  tissues 
outside  the  joint  proper,  in  the  sheaths  of  the  tendons  of  muscles, 
or  in  the  fascia  of  the  soles  of  the  feet.  The  swelling  is  frequently 
quite  marked.  In  chronic  cases  there  may  be  effusion  ("  water  on 
the  joint").  In  very  severe  cases  suppuration  occurs  (abscess 
forms).  The  eye  and  the  heart  may  also  be  seriously  involved. 

Treatment  is  not  very  satisfactory.  Give  a  teaspoonful  of  elixir 
of  iron,  quinine,  and  strychnine  three  times  a  day  before  meals,  and 
from  5  to  10  grains  (0.3  gm.  to  0.6  gm.)  iodide  of  potassium  in  a 
little  water  or  in  a  teaspoonful  of  sirup  sarsaparilla  after  meals. 
Keep  the  joint  at  rest.  Apply  a  flannel  bandage.  Change  it  fre- 
quently and  wash  the  joint  with  hot  water  and  soap.  In  chronic 
cases  liniments  and  passive  motion  should  be  applied.  Tincture  of 
iodine  may  be  painted  over  the  joint. 

Syphilitic  rheumatism,  so  called,  is  associated  with  secondary  or 
tertiary  syphilis.  The  joints,  and  the  shafts  of  long  bones  may  be 
affected — thickened  and  painful.  The  pain  is  always  worse  at  night, 
but  this  is  true  to  a  less  degree  of  pain  from  any  cause. 

The  treatment  is  by  iodide  of  potassium,  beginning  with  10  grains 
(0.66  gm.)  of  iodide  of  potassium  three  times  a  day  after  meals  and 
gradually  increasing  the  dose.  Ten  drops  of  the  tincture  of  the  chlo- 
ride of  iron  with  a  grain  (0.1  gm.)  of  quinine  in  a  wineglassful  of 
water  may  be  given  before  meals.  Good  food  and  attention  to  the 
bowels  are  important. 

DELIRIUM    TKEMENS. 

Delirium  tremens  occurs  as  an  incident  in  the  life  of  persons 
addicted  to  the  excessive  use,  or  rather  to  the  abuse,  of  intoxicating 
liquors. 

Loss  of  appetite,  sleeplessness,  or  a  marked  mental  depression  are 
the  chief  symptoms  of  the  first  stage  of  the  affection  which  is  known 
among  drunkards  as  "  the  horrors." 

As  the  disease  advances  the  patient  talks  incoherently,  has  a  wild 
expression,  his  mind  wanders  from  one  thing  to  another,  he  answers 
questions  in  a  rambling  manner,  he  fancies  he  is  being  pursued  by 
wild  animals,  or  that  he  sees  rats,  snakes,  and  other  animals  crawl- 
ing on  the  wTalls  or  around  his  bed.  Or  he  may  imagine  himself  .to  be 
engaged  in  his  regular  duties,  or  as  master  of  the  ship,  giving  direc- 
tions to  the  men. 

The  delirium  is  always  worse  at  night,  but  the  patient  requires 
careful  watching  all  the  time.  He  may  try  to  jump  overboard  and 
commit  suicide. 

Delirium  tremens  may  be  confounded  with  acute  inflammation  of 
the  brain,  or  with  acute  mania  (insanity),  or  with  certain  forms  of 


45 

pneumonia,  and  any  one  of  these  diseases  may  also  be  present.  Pneu- 
monia is  a  frequent  complication  of  delirium  tremens,  and  in  fatal 
cases  may  be  the  direct  cause  of  death. 

In  favorable  cases  the  symptoms  begin  to  improve  in  three  or  four 
days  from  the  onset,  the  patient  sleeps  and  gradually  recovers. 

Treatment. — The  patient  requires  constant  attendance.  Physical 
restraints  should  be  avoided  if  possible.  To  support  the  patient  and 
to  procure  sleep  are  the  great  objects  of  treatment.  Careful  feeding 
is  very  important.  Milk  or  concentrated  broths  should  be  given  at 
regular  intervals  of  two  hours.  A  cold  bath  is  of  value  in  some 
cases,  especially  if  agreeable  to  the  patient.  In  other  cases  a  warm 
bath  or  a  hot  footbath  may  have  a  better  effect.  The  continuation  of 
alcoholic  stimulants  in  small  or  moderate  quantities  may  be  advisable 
in  some  cases.  'A  few  drops  of  tincture  of  capsicum  or  tincture  of 
ginger  may  be  given  in  water  or  in  a  little  whisky  and  water  every 
two  or  three  hours. 

The  serious  symptoms  are  largely,  if  not  entirely,  due  to  the  sleep- 
lessness, and  if  several  hours  of  sound  sleep  can  be  procured  improve- 
ment is  almost  sure  to  follow.  To  this  end  bromide  of  potassium  in 
30-grain  (2  gm.)  doses  may  be  given  in  water  every  three  hours, 
morphia  or  opium  are  not  to  be  recommended  in  this  disease  except 
under  the  immediate  direction  of  a  physician. 

SYPHILIS. 

Syphilis  is  a  constitutional  disease.  It  is  contagious,  or  commu- 
nicable, and  is  usually  acquired  during  sexual  contact.  It  may,  how- 
ever, be  contracted  in  many  different  ways,  direct  and  indirect.  It 
begins  by  a  primary  lesion  or  sore  called  a  chancre  at  the  seat  of  inoc- 
ulation (where  the  virus  enters),  and  is  followed  by  eruptions  of  the 
skin  of  different  forms  and  different  degrees  of  severity  and  variable 
duration.  Sores  also  appear  at  the  angle  of  the  mouth,  and  mucous 
patches  develop  on  the  lips,  tongue,  inner  sides  of  the  cheeks,  and 
sore  throat  is  very  common. 

Mucous  patches  or  syphilitic  warts  are  also  frequently  seen  about 
the  anus  or  in  any  region  where  the  skin  is  moist.  The  hair  fre- 
quently falls  out,  the  eyes  are  sometimes  seriously  involved,  and  sooner 
or  later  every  organ  in  the  body  may  become  affected.  A  man  suffer- 
ing from  syphilis  in  active  form  should  not  be  allowed  to  go  on 
board  a  ship,  and  if  the  disease  breaks  out  while  on  the  voyage  he 
should  be  isolated,  or  at  least  be  compelled  to  use  separate  drinking 
cups,  knives,  spoons,  forks,  towels,  etc.  He  should  under  no  circum- 
stances smoke  the  pipe  belonging  to  another  man  nor  allow  another 
man  to  smoke  his  pipe.  All  his  belongings  should  be  kept  strictly  to 
himself,  for  unless  the  greatest  care  is  taken  other  men  of  the  crew 


46 

will  suffer.  Chancre  of  the  lip  may  be  acquired  by  smoking  the  pipe 
of  a  syphilitic. 

The  primary  or  initial  lesion  of  syphilis  (the  hard  chancre)  usually 
appears  about  three  weeks  after  exposure,  but  may  be  as  early  as  ten 
or  twelve  days  or  as  late  as  five  or  six  weeks.  It  begins  as  a  red  spot, 
or  papule,  which  usually  breaks  and  forms  a  small  ulcer  with  hard 
edges;  sometimes  the  sore  appears  as  a  simple  excoriation  or  super- 
ficial ulcer  without  hard  edges.  The  neighboring  lymph  glands 
become,  in  the  course  of  a  week  or  two,  enlarged  and  hard.  They 
seldom  suppurate.  About  a  month  or  six  weeks  later  the  skin  erup- 
tion and  other  secondary  symptoms  begin.  The  lymph  glands  above 
'the  elbow,  along  the  side  and  back  of  neck,  and  all  over  the  body  are 
usually  enlarged.  Patient  frequently  complains  of  headache  and 
pain  in  the  limbs,  always  worse  at  night,  and  may  have  slight,  occa- 
sionally considerable  fever. 

Treatment. — For  the  primary  sore  bathe  the  part  with  soap  and 
water,  and  dust  calomel  or  bismuth,  or  oxide  of  zinc,  or  a  mixture  of 
these  remedies  over  the  sore  twice  a  day ;  or  instead  of  the  powder 
"  black  wash  "  may  be  applied,  or  in  some  cases,  if  there  is  much  irri- 
tation or  suppuration,  iodoform  may  have  a  better  effect. 

If  secondary  symptoms,  eruptions  of  skin,  etc.,  appear,  give  a  pill 
of  protiodide  (green  iodide)  of  mercury,  -J-  grain  (0.01  gm.),  three 
times  a  day.  The  mouth  and  teeth  should  be  kept  clean  by  means  of 
a  soft  toothbrush  and  castile  soap  and  water,  or  water  to  which  a 
small  quantity  of  bicarbonate  of  soda  (baking  soda)  or  tincture  of 
myrrh  has  been  added.  If  mucous  patches  appear  in  the  mouth 
smoking  must  not  be  allowed.  As  soon  as  the  ship  arrives  in  port 
send  or  take  the  man  to  the  Marine-Hospital  office  and  receive  the 
advice  of  a  surgeon  as  to  further  treatment. 

SOFT    CHANCRE   ( CHANCROID). 

Soft  chancre  or  chancroid  is  a  virulent  ulcer.  It  usually  begins 
within  twenty- four  or  thirty-six  hours  after  exposure,  first  as  a  red 
spot,  but  rapidly  developing  into  an  ulcer  covered  with  thick  yellow- 
ish pus.  The  period  of  development  is  about  three  or  four  days. 
Sometimes  a  week  elapses  from  the  time  of  exposure  to  the  develop- 
ment of  the  sore,  and  occasionally  a  period  of  incubation  is  as  long 
as  ten  days.  A  sore  appearing  within  a  few  days,  or  a  week,  or  even 
as  late  as  ten  days  after  the  exposure  is  usually  regarded  as  a  chan- 
croid. But  in  practice  this  is  not  a  safe  rule,  for  the  reason  that 
many  venereal  sores  are  of  a  mixed  character.  A  hard  or  syphilitic 
chancre  contracted  two  or  three  weeks  ago,  makes  its  appearance 
to-day.  A  soft  chancre  or  chancroid  contracted  two  or  three  days 
ago,  makes  its  appearance  to-day.  The  inoculations  of  both  poisons 


47 

take  place  at  the  one  and  same  spot,  the  result  is  a  mixed  chancre ;  or 
if  two  sores  appear  the  origin  of  one  may  be  syphilitic,  the  other 
chancroidal.  It  is  therefore  difficult,  if  not  impossible,  in  many 
cases  to  determine  the  character  of  the  disease  from  the  period  of 
incubation  or  from  the  appearance  or  local  characteristics  of  the 
chancre.  A  mixed  chancre  is  a  syphilitic  chancre  (a  hard  chancre), 
while  its  appearance  may  be  precisely  like  that  of  the  soft  chancre  or 
chancroid.  The  only  safe  plan  is  to  regard  all  venereal  sores  as  sus- 
picious. But  while  this  is  true,  treatment  for  syphilis  should  not  be 
commenced  before  the  appearance  of  secondary  symptoms,  for  unless 
such  symptoms  appear  it  is  impossible  to  determine  that  syphilis 
really  exists  in  any  case.  The  mixed  chancre,  as  already  stated,  is 
essentially  a  syphilitic  chancre,  and  the  beginning  of  constitutional 
disease.  Its  local  effects,  however,  may  be  precisely  the  same  as  those 
of  soft  chancre  or  chancroid.  The  ulcer  (or  ulcers — sometimes  there 
are  two  or  more)  may  remain  as  small  as  a  pea  or  grow  as  large  as 
a  quarter,  and  if  it  become  phagedenic  (eating)  may  spread  over  a 
large  portion  of  the  surface  of  the  body.  It  is  also  proper  to  state 
that  a  secondary  syphilitic  sore  may  appear  under  the  foreskin,  as 
well  as  at  any  other  place  on  the  body,  and  that  cancer  (epithelioma) 
of  the  organ  may  begin  as  a  small  ulcer.  The  latter,  however,  is  a 
rare  disease  as  compared  with  the  different  varieties  of  chancre,  the 
vast  majority  of  which  are  of  venereal  origin. 

The  most  frequent  complication  of  soft  chancre  or  chancroid  is 
inflammation  of  the  lymph  glands  of  the  groin  (bubo),  known  to 
the  sailor  as  "  blue  balls."  Another  troublesome  and  serious  com- 
plication is  the  elongation  and  contraction  of  the  orifice  of  the  fore- 
skin (phimosis),  on  the  inner  surface  of  which  the  sores  may  be 
located,  and  the  swelling  and  tension  may  be  so  great  as  to  pro- 
duce gangrene  (mortification).  If  the  foreskin  is  very  tight  and 
pulled  back  and  can  not  be  brought  forward  again  the  condition 
is  knowTn  as  paraphimosis,  which  produces  great  swelling,  the  same 
as  if  a  string  were  tied  around  the  organ,  frequently  resulting  in 
severe  ulceration  and  destruction  of  tissue.  This  condition  may 
also  be  the  result  if  the  inflammation  and  swelling  are  marked  and 
the  foreskin  is  very  tight. 

Treatment. — The  best  treatment  for  soft  chancres  or  chancroids  is 
cauterization  with  nitric  acid.  The  parts  should  be  first  thoroughly 
washed  with  soap  and  water,  and  dried.  The  nitric  acid  should 
then  be  carefully  applied  to  the  sore  by  means  of  a  thin  glass  rod, 
taking  care  to  prevent  the  acid  from  running  over  the  surrounding 
tissues,  or  if  it  does  run  over,  then  to  immediately  soak  it  up  by 
means  of  a  piece  of  blotting  paper.  If  the  sore  is  first  touched  with 
carbolic  acid  the  application  of  the  nitric  acid  will  be  less  painful, 


48 

and  the  carbolic  acid  alone  is  probably,  next  to  nitric  acid,  the  best 
local  remedy. 

If  a  glass  rod  is  not  at  hand,  a  wooden  toothpick  or  thin  stick 
may  be  wrapped  with  a  bit  of  absorbent  cotton  and  then  dipped 
into  the  acid  and  applied  to  the  sore.  When  the  cauterization  is 
complete  every  part  of  the  sore  and  a  narrow  border  around  it  will 
be  white.  If  one  application  is  not  sufficient  another  should  be 
tried.  The  sore  should  then  be  dried  and  covered  with  a  small 
piece  of  gauze  or  absorbent  cotton,  and  later  a  dusting  powder  of 
calomel  or  iodoform  or  bismuth  may  be  applied.  If  the  sore  extend 
into  the  opening  of  the  urethra  (the  meatus)  iodoform  had  better  be 
applied  in  place  of  the  acid,  for  if  the  acid  should  run  into  the 
urethra  it  might  result  in  great  harm. 

If  phimosis  exist  the  cavity  of  the  foreskin  should  be  syringed 
out  with  hot  water,  and  if  there  are  sores  under  the  foreskin  Avhich 
can  not  be  reached  by  the  acid  the  cavity  should  be  syringed  with 
a  solution  of  one  part  of  carbolic  acid  to  forty  parts  of  water  (1  to 
40),  or  with  a  solution  of  one  part  of  bichloride  of  mercury  (corro- 
sive sublimate)  to  three  thousand  parts  of  water  (1  to  3,000).  Soft 
chancres  or  chancroids  appearing  at  the  anus  or  rectum  should  be 
treated  by  frequent  washings  of  warm  water  and  the  application  of 
iodoform.  The  strong  acids  must  not  be  applied  to  this  region. 

In  all  cases,  wherever  the  sore  is  located,  cleanliness  must  be  insisted 
upon,  and,  as  already  stated,  in  nearly  all  inflammations  of  whatso- 
ever character,  hot  water  alone  is  a  valuable  remedy;  and  rest  in  bed 
is  of  equal  importance.  If  a  lump  (bubo)  appear  in  the  groin,  rest  in 
bed  is  of  the  greatest  importance.  The  diet  should  be  light  but  nour- 
ishing. Tincture  of  iodine,  pure  or  diluted  one-half  with  alcohol, 
may  -be  painted  over  the  lump,  but  it  is  not  of  much  value.  Rest  is 
the  important  thing.  If  the  bubo  go  on  to  suppuration,  it  should  be 
carefully  opened  with  the  point  of  a  knife,  and  kept  open  by  a  strand 
of  aseptic  gauze,  which  must  be  frequently  changed,  and  enough  gauze 
should  be  placed  on  top  of  the  wound  to  absorb  the  discharges.  The 
soiled  gauze  should  be  burned,  and  the  person  handling  it  must  be 
careful  to  wash  his  hands  in  soap  and  water  and  in  one  of  the  anti- 
septic solutions  already  referred  to.  The  patient's  bowels  should  be 
moved  once  a  day,  and  eight  drops  of  the  tincture  of  chloride  of  iron 
in  water  should  be  given  three  times  a  day,  and  as  soon  as  the  vessel 
arrives  in  port  he  should  be  sent  to  the  Marine-Hospital  surgeon. 

GONORRHEA    (  CLAP  )  . 

Gonorrhea  is  a  specific  inflammation  of  the  urethra  due  to  a  micro- 
organism, called  gonococcus.  It  usually  begins  during  the  first  week 
after  exposure,  sometimes  as  early  as  three  or  four  days  and  occasion- 
ally as  late  as  ten  days  or  two  wreeks.  The  first  symptoms  are  a 


49 

tickling  or  itching  sensation  and  a  slight  swelling  about  the  lips  of  the 
orifice  of  the  urethra.  A  purulent  creamy  colored  discharge  soon 
appears,  and  a  burning  or  stinging  pain  attends  the  passage  of  urine. 
The  inflammation  gradually  extends  to  the  deeper  parts  of  the 
urethra,  and,  unless  checked  by  medication,  reaches  its  height  about 
the  end  of  the  second  or  during  the  third  week.  The  patient  may 
experience  great  difficulty  in  passing  water.  If  the  inflammation  run 
very  high,  abscesses  may  form  in  the  tissues  around  the  urethra,  and 
swelled  testicle  and  bubo  are  frequent  complications;  also  painful 
erections  and  bending  of  the  organ  (chordee).  Phimosis,  or  para- 
phimosis  occurs  if  the  foreskin  is  tight  or  becomes  involved  in  the 
inflammation. 

If  phimosis  occur  and  if  the  cavity  of  the  foreskin  is  not  thor- 
oughly and  frequently  washed  out,  "  venereal  warts  "  are  apt  to  form. 

True  gonorrhea,  if  carefully  treated,  gradually  subsides  and  recov- 
ery may  take  place  in  from  three  to  four  weeks.  A  urethral  discharge 
that  recovers  in  a  few  days  or  a  week  is  probably  a  simple  urethritis. 

Gonorrhea  is  urethritis  (inflammation  of  the  urethra),  but  ure- 
thritis is  not  necessarily  gonorrhea. 

Treatment. — Rest  in  bed,  light  diet,  plenty  of  water  to  drink,  pref- 
erably vichy  or  apollinaris,  regularity  in  eating  and  sleeping.  Keep 
the  bowels  open  by  taking  a  moderate  dose  of  Epsom  or  Bochelle  salts 
in  the  morning.  Avoid  strong  coffee  and  tea,  all  stimulants,  and 
greasy  articles  of  food.  Keep  the  body  and  mind  at  rest.  Bathe 
frequently  in  hot  water.  Be  very  careful  not  to  convey  any  of  the 
pus  from  the  urethra  to  the  eyes.  (Gonorrheal  inflammation  of  the 
eyes  is  a  very  serious  disease,  which  not  infrequently  results  in  total 
blindness  and  loss  of  the  eyes.) 

Give  10  grains  (0.6  gm.)  of  citrate  of  potash  in  water  three  times 
a  day,  also  10  or  15  drops  of  oil  of  sandalwood  three  times  a  day. 
The  sandalwood  oil  may  be  given  in  capsules  or  dropped  on  a  lump 
of  sugar.  If  much  pain  in  the  back  or  over  the  region  of  the  kidneys 
follow  the  use  of  the  sandalwood,  it  must  be  discontinued  for  a  time 
or  the  dose  lessened.  Later  in  the  disease,  about  the  end  of  the  second 
week,  a  mixture  of  balsam  copaiba  may  be  given  in  one  or  two  tea- 
spoonful  doses  three  times  a  day  in  place  of  the  sandalwood,  or  the 
copaiba  may  be  given  in  doses  of  5  or  T  drops  in  capsules. 

If  the  chordee  is  troublesome,  apply  cloths  wrung  out  of  cold  water 
and  give  a  tablet  of  codeine,  one-sixth  grain  (0.01  gm.),  three  times 
a  day. 

When  the  acute  symptoms  of  the  disease -have  subsided  use  an 
injection  of  sulphate  of  zinc,  2  or  3  grains  (0.12  gm.  to  0.2  gm.)  to  an 
ounce  (30  c.  c.)   of  water,  or  1  grain  of  argonin  (0.06  gm.)   to  an 
ounce  (30  c.  c.)  of  water,  three  times  a  day. 
13256—04  M 4 


50 

A  snug  suspensory  bandage  worn  from  the  beginning  may  prevent 
the  complication  of  swelled  testicles.  If  the  patient  is  lying  in  bed, 
the  dragging  of  the  testicles  should  be  prevented  by  placing  them  on 
a  support.  The  best  local  remedy  for  swelled  testicles  is  heat,  which 
may  be  applied  by  pieces  of  cloth  or  flannel  wrung  out  of  hot  water  or 
by  means  of  hot  flaxseed  poultices,  frequently  renewed.  The  flax- 
seed  meal  should  be  thoroughly  moistened  with  hot  water  and  placed 
between  two  layers  of  cheesecloth  or  other  thin  material.  It  should 
then  be  put  around  the  scrotum  and  covered  with  cotton.  Oiled  silk 
or  oiled  muslin  should  be  placed  over  the  cotton  to  retain  the  heat. 

STRICTURE   OF   THE    URETHRA. 

True  or  organic  stricture  of  the  urethra  is  a  narrowing  of  the 
tube.  It  is  commonly  the  result  of  long-continued  or  neglected 
gonorrhea.  Stricture  of  the  urethra  may  be  produced  by  direct 
injuries,  as  kicks  or  falls  on  the  perineum,  or  by  the  use  of  too 
strong  injections,  or  by  the  careless  passage  of  instruments. 

Occasionally  stricture  results  from  simple  urethritis,  not  gonor- 
rheal,  and  symptoms  not  unlike  those  of  stricture  are  sometimes 
caused  by  a  stone  in  the  bladder  obstructing  the  passage,  and  by  an 
enlarged  prostate  gland. 

Gonorrheal  stricture  of  the  urethra  is  usually  of  slow  development. 
It  may  be  several  months  or  years  after  the  attack  of  gonorrhea 
before  the  patient  becomes  conscious  of  any  change  in  the  size  or 
shape  of  the  stream.  First  there  may  be  only  a  twisting  or  flatten- 
ing of  the  stream.  In  severe  cases  it  gradually  becomes  smaller  and 
smaller,  until  it  is  no  larger  than  a  knitting  needle  and  passed  with 
great  difficulty,  or  it  comes  away  drop  by  drop,  and  finally  results 
in  complete  retention.  One  of  the  earliest  symptoms  of  stricture  is 
a  gleety  discharge  from  the  urethra — "  gleet  means  a  stricture/' 

Occasionally  retention  of  urine  is  the  first  symptom  of  the  disease. 

Sudden  retention  may  be  due  to  spasm  of  the  urethra  (spasmodic 
stricture) . 

Spasmodic  stricture  may  occur  independently  of  any  specific  dis- 
ease of  the  urethra,  but  it  is  more  frequently  a  complication  of  organic 
stricture.  Exposure  to  cold  and  wet  (catching  cold),  or  a  debauch, 
are  the  usual  exciting  causes. 

When*  retention  occurs  the  bla,dder  gradually  becomes  distended 
and  a  fullness  or  distinct  tumor  may  be  felt  in  the  lower  part  of  the 
abdomen,  which  in  severe  cases  may  extend  as  high  as  the  navel. 
Sometimes  there  is  an  involuntary  flow,  or  an  overflow  of  urine  from 
a  distended  bladder — patient  says  he  can  not  hold  his  water,  and  in 
such  case  it  may  be  difficult  to  convince  him  that  he  is  suffering  from 
retention,  until  a  catheter  is  passed  and  a  quantity  of  urine  is 
withdrawn. 


51 

Treatment. — A  neglected  stricture  of  the  urethra  is  a  serious  dis- 
ease, the  treatment  of  which  is  very  difficult  in  many  cases,  even  in 
the  hands  of  the  most  experienced  surgeon. 

The  attention  of  the  ship's  captain  is  rarely  called  to  a  case  until 
there  is  an  actual  stoppage  or  retention  of  urine,  and  unless  this 


PIG.  1. — How  to  use  catheter. 


condition   is   relieved   the   consequences   are   extremely   serious   and 
death  may  be  the  result. 

Place  the  patient  on  his  back  with  his  knees  slightly  drawn  up,  and 
try  to  pass  a  catheter.  The  instrument  should  first  be  thoroughly 
cleansed  by  placing  it  in  boiling  water.  It  should  then  be  oiled  with 


FIG.  2. — Shows  the  curve  of  the  channel  through  which  the  catheter  must  pass. 


olive  oil,  and  carefully  passed  into  the  urethra  and  effort  made  with 

the  greatest  gentleness  to  pass  into  the  bladder.    (Figs.  1  and  2.) 

It  is  a  good  plan  to  have  several  sizes  of  catheters  ready  at  the  same 

time,  and  to  try  the  largest  one  (about  a  No.  9  English)  first;  if  this 


52 

fail,  try  the  smaller  ones.  If  a  catheter  can  not  be  passed  at  the  first 
trial,  place  the  patient  in  a  hot  bath,  give  him  a  Dover's  powder,  and 
an  hour  or  two  later  try  the  catheter  again.  If  it  is  not  practicable  to 
place  the  patient  in  a  full  bath  of  hot  water,  then  cover  his  belly 
and  other  parts  of  his  body  with  flannels  wrung  out  of  hot  water  and 
change  them  every  fifteen  minutes.  The  object  of  the  hot  bath  and 
the  Dover's  powder  is  to  produce  relaxation.  Sometimes  a  patient 
will  pass  his  water  in  the  bath.  If,  however,  the  symptoms  are  very 
urgent,  if  the  patient  can  not  pass  any  water,  and  after  the  most  care- 
ful and  gentle  manipulation  the  catheter  can  not  be  passed  into  the 
bladder,  there  is  but  one  thing  left  to  be  done,  and  that  is  to  puncture 
the  bladder  immediately  above  the  bone  (the  pubes)  at  the  lower  part 
of  the  belly.  This  is  done  by  means  of  a  curved  trocar  and  cannula. 
A  very  small  incision  through  the  skin  (about  half  an  inch  long)  is 
first  made  by  a  knife,  the  trocar  and  cannula  are  then  thrust  down- 
ward and  backward  into  the  bladder.  The  trocar  is  then  withdrawn 
and  the  cannula  is  secured  in  place,  a  soft  catheter  is  passed  through 
it,  and  in  this  way  the  bladder  is  emptied.  The  cannula  may  be  kept 
in  place,  if  necessary,  for  several  days.  Before  beginning  this  opera- 
tion the  belly  should  be  carefully  washed  and  scrubbed  with  soap  and 
water  and  then  with  alcohol,  the  instruments  should  be  boiled,  and  the 
operator's  hands  should  be  thoroughly  cleansed. 

If  possible  to  obtain  the  services  of  a  surgeon  in  reasonable  time, 
this  operation  should  not  be  attempted  by  the  captain. 

ITCH  (SCABIES). 

This  trouble  is  produced  by  an  insect  which  burrows  into  the  skin, 
particularly  between  the  fingers  and  between  the  toes,  but  also  at 
other  situations  where  the  skin  is  most  delicate. 

Careful  examination  will  show  small  vesicles  on  the  skin,  but  most 
of  the  eruption  is  due  to  the  scratching.  The  itching  is  always  worse 
at  night.  The  disease  is  spread  by  personal  contact  or  by  clothing. 

Treatment. — Sulphur  ointment  is  the  remedy.  Bathe  or  scrub  the 
body  thoroughly  with  soap  and  water,  dry  the  skin,  and  then  apply 
the  ointment.  Repeat  the  process  once  a  day,  preferably  in  the  even- 
ing, just  before  turning  in,  bathing  with  soap  and  water  each  time 
before  applying  the  ointment. 

BOILS. 

A  boil  is  a  circumscribed  inflammation  of  the  skin  and  connective 
tissue.  It  is  often  caused  by  infection  following  a  slight  wound  or 
scratch  of  the  skin,  but  may  occur  apparently  without  any  cause.  It 
begins  as  a  small  red  pimple,  and  gradually  increases  in  size  and 
forms  a  dusky  red  swelling,  the  size  of  a  silver  dollar  or  less.  The 
central  portion  of  the  swelling  sloughs,  or  forms  a  "  core,"  and  as 


53 

soon  as  the  core  is  separated  or  cast  off,  the  inflammation  subsides,  the 
pain  lessens,  arid  the  ulcer  begins  to  heal. 

Treatment. — Hot  applications — ground  flaxseed  poultice  frequently 
renewed,  until  the  central  portion  of  the  boil  is  softened,  then  the 
separation  of  the  core  may  be  aided  by  an  incision.  The  incision 
should  be  made  by  a  thin  blade,  thoroughly  boiled  before  it  is  used. 
After  the  core  is  discharged  the  ulcer  should  be  dressed  with  aseptic 
gauze,  held  in  place  by  a  bandage. 

PILES. 

Piles  are  varicose  dilatations  of  the  veins  of  the  rectum.  The 
symptoms  may  be  slight  or  severe.  Inflamed  piles  are  very  painful. 
There  is  a  constant  burning  sensation  at  the  anus,  which  is  greatly 
increased  during  and  immediately  after  each  movement  of  the  bowels. 
When  the  veins  rupture  you  have  "  bleeding  piles."  Occasionally 
the  inflammation  of  a  nodule  results  in  an  abscess. 

Treatment. — Piles  are  frequently  due  to  habitual  constipation,  and 
when  that  condition  is  improved  the  piles  often  disappear,  or  at  least 
cease  to  be  troublesome.  The  bowels  should  be  kept  in  good  condi- 
tion. One  easy  movement  should  take  place  regularly  every  day. 
This  desirable  habit  should  be  brought  about  by  careful  attention  to 
diet  and  by  drinking  water  in  the  morning  before  breakfast,  rather 
than  by  the  use  of  cathartics. 

In  acute  attacks,  if  the  bowels  are  constipated  give  a  full  dose  of 
salts;  put  the  patient  on  light,  soft  diet.  Apply  ice  to  the  anus  or 
inject  cold  water  into  the  rectum.  A  hot  application  or  poultice  is 
sometimes  very  grateful.  If  the  piles  protrude,  especially  if  they 
become  strangulated,  they  should  be  pushed  back  with  the  finger; 
oil  or  vaseline  may  be  applied.  If  the  piles  are  large  and  persist- 
ently painful,  see  a  surgeon  and  have  them  removed  by  operation, 
which  is  the  only  sure  cure. 

INJURIES HEMORRHAGE    (BLEEDING). 

In  all  cases  of  injury  careful  examination  should  be  made  of  the 
part,  after  carefully  washing  the  hands. 

^Hemorrhage  is  of  three  kinds — arterial,  venous,  capillary. 

Arterial  (bright-red  blood  from  arteries  in  jets  or  spurts). 

Venous  (dark-red  or  purple  blood  welling  out  or  flowing  from 
veins  in  steady  stream). 

Capillary  (blood  oozing  from  the  capillaries  over  the  general  sur- 
face of  a  wound). 

If  the  bleeding  is  by  jets  or  spurts,  pressure  should  immediately 
be  made  above  the  wound  by  the  thumb  or  finger,  or  better  by  tying 
rubber  tubing  around  the  limb,  or,  in  the  absence  of  such  a  tube,  a 


54 

bandage,  handkerchief,  suspender,  strap,  or  soft  rope  may  be  used  to 
stop  or  lessen  the  flow  of  blood ;  the  blood  vessel  should  then  be  seized 
and  drawn  gently  forward  with  a  "pair  of  artery  forceps  and  the 
ends  tied  with  catgut  or  silk  in  a  reef  knot,  when  the  tubing  or  strap 
should  be  loosened  or  removed. 

If  the  blood  vessel  is  torn  but  not  completely  divided,  tie  a  ligature 
around  the  vessel  on  each  side  of  the  wound. 

Straps  or  bandages  applied  to  control  or  lessen  the  danger  of 
hemorrhage  must  always  be  placed  above  the  wound — that  is  to  say, 
between  the  bleeding  point  and  the  heart.  In  wounds  of  the  foot, 
for  example,  if  the  arteries  spurt,  pressure  should  be  made  in  the 
hollow  back  of  the  knee.  If  the  blood  is  flowing  slowly  or  oozing 
and  does  not  come  by  jets  or  spurts,  gauze  or  lint  wrung  out  of  hot 
water  should  be  applied  and  firmly  bandaged  over  the  wound,  or  hot 
water  may  be  poured  over  the  wound  before  applying  the  gauze  or 
lint.  In  any  case  it  is  well  to  cleanse  the  wound  with  hot  water. 
The  oozing  may  also  be  stopped  by  exposing  the  wound  to  fresh  air 
and  by  allowing  a  stream  of  cold  water  to  fall  upon  it,  and  then  ap- 
plying pressure. 

Before  beginning  the  treatment  of  any  wound  or  any  bleeding 
point,  the  operator  must  carefully  cleanse  his  hands  and  arms,  also 
the  wound  and  surrounding  parts,  and  the  instruments  and  silk  liga- 
ture should  be  boiled  as  will  be  described  under  the  head  of  wounds. 

In  the  after  treatment  of  severe  bleeding  the  patient  should  be  kept 
perfectly  quiet  in  mind  and  body,  his  head  should  be  lowered  by 
raising  the  foot  end  of  his  bed  or  bunk.  Give  him  plenty  of  fresh 
air,  but  keep  his  body  warm  ;md  give  him  hot  drinks.  After  reaction 
the  temperature  of  the  body  may  rise  a  degree  or  two  above  normal, 
but  if  this  should  continue  longer  than  two  or,  at  most,  three  days, 
the  dressing  should  be  removed  and  the  wound  thoroughly  irrigated, 
first  with  hot  water  then  with  a  solution  of  bichloride  of  mercury 
(1  to  5,000),  and  dressed  with  aseptic  gauze. 

WOUNDS. 

Incised  wounds  inflicted  by  sharp  cutting  instruments  may,  after 
the  bleeding  has  been  stopped,  be  drawn  together  with  the  fingers 
or  with  a  needle  and  thread,  a  thin  layer  of  absorbent  cotton  applied 
over  the  wound  and  then  saturated  with  collodion.  Strips  of 
adhesive  plaster  may  be  used  over  the  dressing.  The  parts  should  be 
thoroughly  cleansed,  first  by  scrubbing  with  hot  water  and  soap — the 
skin  to  be  shaved  if  hairy — then  washed  with  alcohol,  and  then  again 
with  hot  water  before  the  edges  are  drawn  together.  The  needle  and 
silk  thread  and  all  instruments  should  be  boiled  before  they  are  used. 
The  operator  must  roll  up  his  sleeves,  scrub  his  hands  and  arms  with 
hot  water  and  soap,  clean  and  trim  his  finger  nails,  scrub  again  with 


55 

soap  and  water,  then  with  alcohol,  and  finally  soak  his  hands  in  a 
solution  of  bichloride  of  mercury  (1  to  1,000)  before  beginning  the 
operation.  The  wound,  if  deep,  should  not  be  completely  closed,  one 
end  should  be  left  open  for  drainage,  unless  the  patient  is  under  the 
direct  care  and  treatment  of  a  surgeon. 

Contused  and  lacerated  wounds  with  torn  and  ragged  edges,  espe- 
cially if  the  surrounding  parts  are  bruised  or  crushed,  should  not  be 
drawn  tightly  together.  The  bleeding  from  lacerated  wounds  at  the 
time  of  the  accident  is  not  so  profuse  as  in  incised  wounds,  but  the 
shock  is  greater,  and  very  troublesome  and  serious  hemorrhage  may 
come  on  within  a  few  hours  or  later.  To  guard  against  this  the 
wound  should  be  carefully  examined  (the  operator's  hands  and  all 
instruments  to  be  first  prepared  as  above  described),  and  if  any  blood 
vessels  have  been  torn  they  should  be  tied  with  silk  ligatures,  though 
they  may  not  be  bleeding  at  the  time.  Sweet  oil  should  then  be 
rubbed  over  the  surface  and  the  edges  of  the  wound  and  adjacent  skin, 
and  this  in  turn  scrubbed  off  with  soap  and  warm  water,  and  then 
with  alcohol,  and  finally  with  a  solution  of  bichloride  of  mercury  (1 
to  5,000).  Thick  layers  of  clean  (sterile)  gauze  dressing  should  then 
be  applied  and  held  in  place  by  means  of  a  bandage.  If  the  wound  is 
large,  the  edges  of  a  portion  of  it  may  be  carefully  drawn  together. 
A  strand  of  gauze  should  then  be  placed  in  the  bottom  of  the  wound 
and  allowed  to  project  through  the  opening  to  the  surface,  so  that  it 
may  drain  into  the  layers  of  gauze  placed  on  top. 

When  dressings  become  soaked  with  the  discharges  they  do  more 
harm  than  good;  they  must,  therefore,  be  changed  as  soon  as  the 
soaking  is  apparent,  and  the  change  must  be  made  with  all  the 
aseptic  precautions  exercised  in  the  operation.  Clean  hands,  clean 
instruments,  clean  dressings,  clean  everything,  are  the  watchwords. 
Water  that  has  been  boiled  is  perfectly  safe,  and  boiling  is  the  best 
disinfectant  for  instruments. 

The  stitches  may  be  removed  from  a  wound  about  the  fifth  or 
sixth  day,  or  earlier  if  they  begin  to  cut  or  irritate.  If  the  wound 
is  large  they  need  not  all  be  taken  out  at  the  same  time. 

Gunshot  wounds  are  frequently  more  or  less  contused  and  lacer- 
ated, and  unless  one  of  the  main  blood  vessels  is  divided,  or  the  lung 
or  other  internal  organ  penetrated,  the  bleeding  is  slight.  The 
general  treatment  for  such  wounds  is  about  the  same  as  for  other 
lacerated  wounds  already  described,  but  if  the  materials  for  thor- 
oughly cleansing  the  wound  are  not  readily  at  hand,  and  if  there 
is  not  much  bleeding,  the  wound  had  better  be  let  alone,  simply  cover- 
ing it  with  antiseptic  gauze  until  the  patient  can  be  placed  under  the 
care  of  a  surgeon.  No  effort  should  be  made  by  the  master  to  find 
or  feel  the  bullet  or  other  missle  by  a  probe  or  other  instrument, 
especially  if  the  wound  is  in  the  chest  or  abdomen,  as  there  is  more 


56 

danger  in  searching  for  it  than  in  leaving  it  where  it  may  be  lodged. 
The  wound  made  by  a  Mauser  bullet  not  infrequently  looks  as  if 
made  by  a  large  needle — a  punctured  wound. 

Punctured  wounds  are  made  by  a  narrow  sharp-pointed  instru- 
ment, e.  g.,  pin,  needle,  dagger,  or  point  of  a  knife  or  stiletto.  They 
may  penetrate  to  any  depth,  and  if  the  instruments  are  clean  and 
no  large  blood  vessels  or  nerves  have  been  wounded,  withdrawal 
of  the  instrument  may  be  followed  by  rapid  recovery.  But  if  such 
wounds  are  produced  by  irregularly  shaped  blunt  instruments,  or 
by  nails  or  splinters  of  wood,  and  especially  if  contaminated  by  any 
poisonous  material,  the  walls  of  the  wound  track  are  at  once  dan- 
gerously contused,  lacerated,  and  infected,  and  if  large  blood  vessels, 
nerves,  or  other  organs  have  been  injured  the  danger  is  very  great, 
and  the  patient  should  be  placed  under  the  care  of  a  surgeon  as 
soon  as  possible,  for  unless  the  master  is  sufficiently  familiar  with 
the  nature  of  such  wounds  and  the  anatomy  of  the  part  to  lay  it  open 
to  the  bottom  by  additional  incisions,  he  can  do  little  more  than 
apply  antiseptic  dressings  to  the  surface,  and  keep  the  patient  quiet. 

BURNS  OR  SCALDS. 

Burns  or  scalds  are  serious,  and  dangerous  to  life  in  proportion 
to  the  extent  and  depth  of  the  injury.  A  burn  covering  a  large 
area  and  producing  mere  reddening  and  swelling  of  the  skin  is  as 
serious  as  a  burn  one-half  the  size  in  which  the  skin  is  destroyed. 
The  danger  is  from  shock ;  from  fever  following  reaction ;  from  hem- 
orrhage following  sloughing,  and  from  congestion  and  inflammation 
of  internal  organs.  Burns  of  slight  extent  or  moderate  degree  are 
not  so  dangerous,  and  most  of  the  cases  commonly  met  with  will 
recover.  But  all  cases  require  careful  treatment. 

Treatment. — For  shock  give  whisky  or  brandy.  In  slight  or  mod- 
erate burns  or  sunburn  apply  clean  cloths  wet  with  warm  satu- 
rated solution  of  bicarbonate  of  soda  (baking  soda) .  In  severe  burns, 
cut  away  the  clothing,  avoid  exposure  to  cold,  wash  the  part  with 
warm  saturated  solution  of  bicarbonate  of  soda,  or  with  solutions 
of  borax  or  boric  acid.  The  parts  burned  or  the  entire  body,  except 
the  head,  may  be  kept  immersed  in  tepid  or  warm  water  for  days. 
Prick  the  blister  with  a  clean  (aseptic)  needle,  but  do  not  remove 
the  cuticle.  Sprinkle  with  dry  bicarbonate  of  soda  or  with  powdered 
borax  and  dress  the  part  with  thick  layers  of  clean  (asceptic)  cotton. 
(Cotton  may  be  rendered  aseptic  by  heating  it  in  an  oven  to  a  point 
just  short  of  burning.)  The  dressing  should  be  changed  only  when 
absolutely  necessary.  Keep  the  patient  quiet  and  his  bowels  active. 
Pain  or  restlessness  may  be  relieved  by  morphine  sulphate,  \  grain 
(0.01  gm.),  repeated  in  two  hours  if  necessary.  Carron  oil  (equal 
parts  of  linseed  oil  and  lime  water)  is  an  old  remedy  that  affords 


57 

considerable  relief  if  applied  to  the  surface.  Vaseline  is  also  some- 
times used.  The  scars  resulting  from  burns  and  scalds  always  con- 
tract, and  in  severe  cases  terrible  deformities  are  produced.  These 
may  be  prevented  to  some  extent  by  active  and  passive  motion  and 
by  splints. 

EFFECTS  OF  COLD FROSTBITE. 

Severe  cold  depresses  the  action  of  the  heart — suspends  the  circu- 
lation. These  effects  are  first  noticed  in  the  ears,  nose,  fingers,  and 
toes.  Numbness  and  tingling  are  the  first  symptoms,  then  loss  of 
sensation.  If  not  too  long  exposed,  the  circulation  may  be  restored 
by  proper  treatment.  But  if  the  exposure  is  long  continued,  or  if 
the  cold  is  very  intense,  the  parts  are  hopelessly  frozen  and  gangrene 
will  be  the  result.  The  parts  may  look  all  right  for  a  few  days  after 
reaction,  arid  then  become  discolored,  bluish,  and  finally  black. 
Another  effect  of  extreme  cold  is  an  overpowering  sense  of  drowsi- 
ness, but  to  lie  down  under  such  circumstances  and  go  to  sleep  is 
almost  certain  death. 

Treatment  of  frostbites,  as  recommended  l>y  the  Surgeon-Gen- 
eral.— 1.  Do  not  bring  the  patient  to  the  fire,  nor  bathe  the  parts  in 
warm  water. 

2.  If  snow  be  on  the  ground,  or  accessible,  take  a  woolen  cloth  in 
the  hand,  place  a  handful  of  snow  upon  it,  and  gently  rub  the  frozen 
part  until  the  natural  color  is  restored.     In  case  snow  is  not  at  hand, 
bathe  the  part  gently  with  a  woolen  cloth  in  the  coldest  fresh  water 
obtainable — ice  water  if  practicable. 

3.  In  case  the  frostbite  is  old  and  the  skin  has  turned  black  or 
begun    to  scale  oft',  do  not  attempt  to  restore  its  vitality  by  friction, 
but  apply  carron  oil  on  a  little  cotton;  after  which  wrap  the  part 
loosely  in  flannel. 

4.  In  all  cases,  as  soon  as  the  vitality  has  been  restored,  apply  the 
carron  oil,  prepared  according  to  Service  formula.     As  it  contains 
opium,  do  not  administer  morphia  or  other  opiate. 

5.  In  the  case  of  a  person  apparently  dead  from  exposure  to  cold, 
friction  should  be  applied  to  the  body  and  the  lower  extremities,  and 
artificial  respiration  practiced  as  in  cases  of  the  apparently  drowned. 
As  soon  as  the  circulation  appears  to  be  restored,  administer  spirits 
and  water  at  intervals  of  fifteen  or  twenty  minutes  until  the  flesh 
feels  natural.     Even  if  no  signs  of  life  appear,  friction  should  be 
kept  up  for  a  long  period,  as  instances  are  on  record  of  recovery  after 
several  hours  of  suspended  animation. 

Carron  oil — (Service  formula)  : 

Olive  oil  or  linseed  oil  (raw). 
Limewater,  of  each  12  parts. 
Tincture  of  opium,  1  part. 
Mix. 


58 

«CALP  WOUNDS. 

Treatment. — Examine  the  parts  carefully ;  clip  and  shave  the  hair 
from  a  wide  area  about  the  wound;  wash  with  warm  water;  draw 
the  edges  of  wound  together  with  the  fingers  and  apply  absorbent 
cotton  and  collodion.  Stitches  of  silkworm  gut,  silver  wire,  or  catgut 
may  be  used.  The  stitches  must  not  be  drawn  tightly,  the  edges 
simply  brought  together.  Bleeding  is  often  severe,  but  usually  stops 
under  pressure  or  after  the  stitches  have  been  put  in  and  the  dressing 
applied.  But  if  an  artery  spurts  it  must  first  be  tied.  A  few  strands 
of  silkworm  gut  may  be  put  in  at  the  most  dependent  part  of  the 
wound  for  drainage,  but  this  is  not  usually  necessary.  No  part  of 
the  scalp  should  be  removed,  no  matter  how  slender  its  attachment. 
If  replaced  it  will  probably  retain  its  vitality.  Dress  the  wound  with 
a  pad  of  clean  (aseptic)  gauze  and  apply  a  bandage,  not  tightly. 

The  stitches,  if  of  silkworm  gut  or  wire,  should  be  removed  the 
fourth  or  fifth  day.  Unconsciousness  and  bleeding  from  the  ears  are 
grave  symptoms,  indicating  fracture  of  base  of  skull  or  rupture  of 
blood  vessels  within. 

WOUNDS  OF  THE  FACE. 

Treatment. — Wounds  of  the  face  may  be  treated  in  the  same  man- 
ner as  wounds  of  the  scalp,  using  fine  silkworm  gut  or  catgut  for 
sutures,  but  greater  care  must  be  exercised  in  introducing  the  stitches, 
and  the  edges  should  be  brought  into  accurate  apposition.  The 
stitches  should  be  removed  on  the  third  day,  and  narrow  strips  of 
adhesive  plaster  applied  over  a  light  dressing  placed  next  the  wound, 
as  adhesive  plaster  should  never  come  in  direct  contact  with  the  edges 
of  a  wound;  and  if  the  wound  is  small,  adhesive  strips  or  cotton  and 
collodion  may  answer  the  purpose  from  the  beginning,  without 
stitches. 

INJURIES    TO    THE    CHEST. 

Contusions  of  the  chest  and  fracture  of  the  ribs  are  of  frequent 
occurrence,  and  it  is  not  always  easy  to  determine  in  a  given  case 
of  injury  to  the  chest  walls  whether  fracture  actually  exists,  but  if 
in  doubt,  give  the  patient  the  benefit,  and  treat  the  case  as  one  of 
fracture. 

Fracture  involving  several  ribs,  or  one  or  more  ribs  at  two  points 
each,  is  not  difficult  to  make  out,  for  in  addition  to  the  sharp  pain 
in  breathing,  and  the  bloody  expectoration  which  is  present  in  cases 
where  the  lung  is  wounded,  there  is  considerable  deformity. 

In  single  fracture  of  the  ribs  there  is  little  or  no  deformity,  but 
the  pain  in  breathing  and  coughing  is  apt  to  be  severe.  Pressure 
on  the  broken  bone  is  also  quite  painful,  and  if  a  hand  is  placed 
over  the  seat  of  injury,  or  a  finger  on  either  side  of  the  fracture,  and 


59 

the  patient  requested  to  cough,  a  grating  may  be  felt,  unless  the  rib 
is  covered  with  heavy  muscle  or  fat,  when,  as  before  stated,  it  may 
be  difficult  if  not  impossible  to  say  whether  or  not  fracture  exists. 

Treatment. — Strips  of  adhesive  plaster,  3  or  4  inches  wide,  and 
long  enough  to  extend  from  the  spine  to  the  middle  or  a  little  beyond 
the  middle  of  the  breastbone,  should  be  applied  horizontally  from 
the  armpits  downward  over  the  whole  side  of  the  chest.  Each  piece 
to  be  forcibly  applied  at  the  end  of  expiration  (when  the  lungs  are 
empty)  and  to  overlap  the  preceding  piece  to  one-half  its  width. 
Any  slight  outward  deformity  at  the  seat  of  fracture  may  be  reduced 
by  pressure  before  the  plaster  is  applied  at  that  point.  A  broad 
bandage  should  then  be  applied  around  the  chest  from  below  upward. 

INJURIES    TO    THE    BACK. 

Sprains  of  the  spine  are  of  all  degrees  of  severity.  In  slight 
sprains  the  muscles  alone  are  involved,  and  beyond  a  temporary 
stiffness,  and  pain  over  a  limited  area,  there  may  be  no  trouble. 

In  severe  sprains  it  is  difficult  to  determine  the  degree  of  injury. 
Marked  pain  and  stiffness  are  always  present,  and  not  infrequently 
paralysis  of  the  legs,  bowels,  and  bladder.  Death  may  be  produced 
by  shock,  or  occur  later  from  secondary  effects  of  the  injury". 

Treatment. — Rest  in  bed.  Epsom  salts  to  move  the  bowels;  rub 
the  back  with  soap  liniment.  Apply  a  binder  or  bandage  around 
the  body  from  the  hips  up  over  the  chest.  Give  Dover's  powder  for 
pain  and  restlessness,  and  repeat  the  same  if  necessary  in  two  or 
three  hours.  See  that  the  bladder  does  not  become  distended.  If 
necessary  introduce  a  catheter  and  draw  off  the  urine. 

BROKEN    BONES     ( FRACTURES). 

There  are  many  varieties  of  fracture.  A  fracture  is  said  to  be 
simple  where  there  is  no  open  wound  directly  over  the  bone  injury; 
compound  when  there  is  an  opening  in  the  skin  and  soft  parts  extend- 
ing down  to  the  broken  bone;  comminuted  when  the  bone  is  broken 
in  several  places;  complicated  when  associated  with  other  injuries,  as 
dislocation  of  the  joint  or  rupture  of  the  main  artery  of  the  limb; 
impacted  when  one  fragment  is  driven  into  another. 

The  reliable  signs  or  symptoms  of  simple  fracture  are  deformity, 
crepitus  (grating)  when  tlie  ends  of  the  broken  bone  are  rubbed 
together,  unnatural  or  false  point  of  motion,  and,  if  in  the  shaft  of  a 
long  bone,  shortening,  due  to  the  fact  that  in  most  cases  the  break  is 
obliquely  across  the  bone  and  the  fragments  override.  But  in  trans- 
verse fracture,  where  the  break  is  straight  across  the  bone  at  a  right 
angle  with  the  long  axis  of  the  bone,  or  in  a  fracture  near  a  joint, 
there  may  be  no  shortening  and  no  deformity.  In  fractures  of  cer- 


60 

tain  bones,  as  the  skull  or  the  spine,  or  in  an  impacted  fracture,  there 
may  be  no  motion.  In  fracture  of  the  kneepan  or  the  elbow  the  frag- 
ments are  pulled  apart  by  the  muscles,  so  there  is  lengthening  instead 
of  shortening. 

Examination  should  always  be  made  as  soon  as  possible  after  the 
accident.  Under  the^  most  favorable  circumstances  it  is  difficult  in 
some  cases  to  determine  whether  a  bone  is  broken  or  not,  and  the 
difficulty  is  greatly  increased  if  the  examination  is  delayed  until 
inflammatory  swelling  has  set  in.  In  fractures  of  the  extremities  the 
sound  limb  should  always  be  placed  alongside  the  injured  one  for 
comparison.  The  shortening  in  fracture  of  the  thigh  may  be  from 
1  to  3  inches,  but  it  must  not  be  forgotten  that  in  some  persons  there 
is  a  natural  difference  of  as  much  as  half  an  inch  in  length  of  the 
pair  of  legs ;  and  a  limb  may  be  otherwise  naturally  deformed  which 
should  not  be  mistaken  for  accidental  deformity.  In  the  leg  belowr 
the  knee  there  are  two  parallel  bones  (tibia  and  fibula).  In  simple 
fracture  affecting  only  one  of  these  bones  the  shortening  and  deform- 
ity and  crepitus  are  less  marked ;  and  the  same  may  be  said  of  the 
forearm,  if  fracture  exists  in  only  one  of  the  bones  (radius  or  ulna). 
If  both  bones  of  the  leg  (tibia  and  fibula)  or  of  the  arm  (radius  and 
ulna)  are  affected,  there  may  be  considerable  deformity,  and  it  is  a 
curious  fact  that  fracture  of  these  bones  seldom  occurs  on  the  same 
level.  The  distance  between  the  fractures  may  be  from  1  to  3  inches, 
usually  greater  in  the  leg  than  in  the  forearm. 

Crepitus  (the  sound  heard,  or  feeling  imparted  to  the  hand  when 
the  broken  ends  of  the  bone  are  rubbed  together)  is  a  valuable  symp- 
tom of  fracture,  but  it  can  not  always  be  detected,  and  when  other 
marked  signs  or  symptoms  are  present,  need  not  and  should  not  be 
looked  for.  In  fractures  of  the  leg  below  the  knee  or  of  the  forearm, 
involving  only  one  of  the  bones,  it  is  hard  to  make  out  because  of  the 
difficulty  of  rubbing  the  broken  ends  together,  and  Avhen  much  swell- 
ing exists  the  difficulty  is  increased,  or  a  false  crepitus  may  be  pro- 
duced. In  impacted  fractures,  which  occur  chiefly  in  the  neck  of  the 
thigh  bone,  no  effort  should  be  made  to  obtain  crepitus.  The  impor- 
tant thing  in  such  cases  is  not  to  disturb  the  impacted  fragments,  for 
if  pulled  apart  recovery  is  rendered  more  difficult. 

FRACTURE    OF    THE   LOWER    JAW. 

Fracture  of  the  lower  jaw  may  be  simple,  compound,  or  com- 
minuted. The  mucous  membrane  of  the  mouth  is  nearly  always 
lacerated,  the  bleeding  is  usually  not  severe  (oozing  only),  but  there 
may  be  hemorrhage  from  an  artery  (the  inferior  dental),  saliva  drib- 
bles from  the  half -open  mouth,  the  teeth  may  be  out  of  line,  pain  is 
apt  to  be  severe,  there  may  be  considerable  deformity  and  a  false 
point  of  motion. 


61 

Treatment. — Restore  the  parts  to  the  natural  position  and  keep 
them  at  perfect  rest,  first  washing  out  the  mouth  with  hot  water  to 
cleanse  it  and  check  bleeding.  If  the  bleeding  is  very  severe  pressure 
should  be  made  by  the  thumb  or  finger  for  a  time  on  the  bleeding 
point  if  possible,  or  on  the  large  artery  (carotid)  on  the  side  of  the 
neck,  which  may  be  easily  located  by  the  pulsation.  Loose  teeth  or 
pieces  of  bone  should  not  as  a  rule  be  removed.  Mold  them  into 
place,  bring  the  teeth  and  jaw  into  natural  line,  and  keep  them  so  by 
a  pasteboard  or  binder's  board  splint  (figs.  3  and  4),  held  in  place  by 
a  four-tailed  bandage. 


H-H 


FIG.  3. 

FIG.  4. 


FIG.  5. 


FIG.  6. 

Fig.  3  shows  the  pasteboard  or  leather  as  cut  out ;  Fig.  4  shows  the  same  molded  to  fit 
the  chin  and  jaw  ;  Fig.  5  is  a  four-tailed  bandage,  and  Fig.  6  shows  how  they  are 
applied. 

Take  a  piece  of  pasteboard  about  8  or  9  inches  long  by  4  inches 
wide  and  cut  it  up  in  the  middle  from  each  end  to  within  about  an 
inch  or  inch  and  a  half  from  the  center,  according  to  the  size  of  the 
chin.  Dip  it  in  hot  water  and  moM  it  to  the  chin  and  jaw.  (Fig.  4.) 

Remove  it  carefully,  line  it  with  absorbent  cotton,  reapply  it,  and 
retain  it  in  place  by  the  four-tailed  bandage.  (Fig.  5.)  The  four- 
tailed  bandage  may  be  made  in  the  following  manner:  Take  a 
bandage  or  piece  of  heavy  muslin  about  3  inches  wide  and  a  yard  or 
a  yard  and  a  half  long.  In  the  middle  of  this  or  a  little  to  one  side  of 


62 

the  middle  cut  a  slit  large  enough  for  the  point  of  the  chin ;  place  the 
narrower  portion  upward,  then  tear  the  bandage  down  the  middle 
from  each  end  to  within  2  inches  of  the  slit,  so  as  to  make  four  ends  or 
tails;  then  carry  the  two  upper  ends  backward  and  tie  at  the  nape  of 
the  neck ;  carry  the  two  lower  tails  to  the  top  of  the  head  and  tie  in  a 
knot.  ( Fig.  6. )  The  ends  of  the  knots  at  nape  of  neck  and  top  of  head 
may  then  be  tied  together  to  hold  them  in  place  and  prevent  slipping. 
If  necessary,  a  bandage  may  also  be  carried  around  the  head  and 
secured  with  pins.  A  splint  of  this  kind  may  also  be  made  of  gutta- 
percha. 

If  the  parts  can  not  be  kept  in  place  by  the  methods  described,  the 
teeth  may  be  fastened  together  with  silver  wire  passed  between  the 
teeth  on  each  side  of  the  break  and  twisting  the  ends  together.  Feed 
the  patient  on  liquid  food  through  a  rubber  tube  introduced  behind 
the  last  tooth  or  through  any  space  left  by  the  loss  of  a  tooth,  the 
object  being  to  prevent  movement  of  the  jaw.  Wash  out  the  mouth 
frequently  with  hot  water,  and,  if  necessary,  change  the  dressing 
every  two  or  three  days  until  the  end  of  about  the  sixth  or  eighth 
week,  when,  if  all  goes  well,  union  will  be  complete,  and  the  splint  and 
bandage  may  be  discontinued. 

FRACTURE   OF    THE    THUMB   AND   FINGERS. 

Treatment. — Put  the  fragments  in  place  by  extension  and  pressure ; 
then  cut  a  piece  of  pasteboard,  leather,  cigar  box,  or  thin  board  long- 
enough  to  extend  from  above  the  wrist  joint  to  a  little  below  the  ends 
of  the  fingers  and  a  little  wider  than  the  hand.  Cover  the  board  with 
lint  or  any  soft  cloth,  place  the  palm  of  the  hand  flat  upon  it,  and 
apply  a  bandage  around  the  whole  hand  and  wrist. 

If  pasteboard  or  leather  be  used,  it  may  first  be  dipped  into  hot 
water  and  then  molded  to  the  shape  of  the  thumb  or  finger  and  palm 
of  the  hand,  then  lined  or  covered  with  cloth,  and  bandaged  as  above, 
care  being  taken  not  to  make  the  bandage  too  tight. 

FRACTURE    OF   THE    FOREARM. 

The  forearm  extends  from  the  wrist  to  the  elbow.  When  both 
bones  are  broken  there  is  apt  to  be  marked  displacement  and  crepi- 
tus  (grating  felt  by  rubbing  the  broken  ends  of  the  bone  together). 
When  only  one  bone  is  broken  the  signs  and  symptoms  are  not  so 
clear,  but  by  careful  examination  the  nature  of  the  injury  may  be 
determined.  When  fracture  of  one  of  the  bones  (the  radius)  occurs 
near  the  wrist  joint  (Colics'  fracture)  there  is  generally  marked 
deformity  resembling  a  silver  fork  in  shape. 

Treatment. — Prepare  two  splints  of  thin  board  or  heavy  binder's 
board,  one  for  the  palmar  side  of  the  forearm  long  enough  to  extend 


63 


from  the  elbow  to  the  palm  of  the  hand.  The  other  for  the  back  of  the 
forearm  may  be  a  little  shorter,  but  should  extend  from  the  elbow  to 
below  the  wrist  back  of  the  hand.  Both  splints  must  be  a  little  wider 
than  the  arm  so  as  to  prevent  the  bones  from  being  drawn  together 
by  the  bandage.  Line  the  splints  with  several  layers  of  lint,  or  with 
absorbent  cotton  or  soft  cloth.  If  deformity  exists,  reduce  it  by  ex- 
tension and  counter  extension.  Pull  on  the  hand  while  an  assistant 
holds  or  pulls  at  the  elbow,  and  gently  press  the  projecting  fragment 
to  its  normal  position.  Place  the  arm  between  the  splints  in  such  a 
way  that  when  bent  at  an  angle  the  thumb  will  point  directly  upward, 
and  the  palm  of  the  hand  lie  flat  against  the  chest.  Apply  a  roller 
bandage  outside  and  around  the  splints  from  fingers  to  elbow,  being 
careful  not  to  make  it  too  tight,  and  hang  the  forearm  in  a  broad 
sling. 

Another  way  to  hold  the  splints  in  place  is  to  apply  strips  of  adhe- 
sive plaster  around  them,  one  at  the  upper  and  the  other  at  the  lower 
end.  If  swelling  occurs,  the  bandage  must  be  loosened.  The  splints 
should  be  worn  six  weeks  or  two  months,  and  passive  motion — that  is, 
gently  bending  and  straightening  of  the  fingers  with  the  other  hand- 
must  be  made  every  few  days  to  prevent  stiffening. 

FRACTURE    OF   THE    ARM     (BETWEEN    THE    ELBOW    AND    SHOULDER). 

Treatment. — Splints  of  binder's  board  dipped  in  water  and  molded 
to  the  part,  or  any  thin  board  will  answer  the  purpose  if  properly 


FIG.  7. 


FIG.  8. 


lined  or  padded.  Place  one  splint  on  the  outside  of  the  arm  extend- 
ing from  the  elbow  to  the  shoulder  (fig.  7),  an  internal  angular  splint 
extending  from  the  armpit  to  the  fingers  on  the  inner  side  (fig.  8), 
and  if  need  be  a  narrower  splint  in  front  and  one  behind,  and  the 
whole  surrounded  with  a  well-fitted  bandage.  Support  the  forearm 
by  a  sling,  but  leave  the  elbow  free.  (Fig.  9.) 

If  much  swelling  occurs,  all  bandages  must  be  loosened. 

The  splint  should  be  worn  about  eight  weeks.     Und£r  the  most 


64 

favorable  circumstances,  after  fracture,  this  bone  (the  humerus) 
sometimes  fails  to  unite. 

Fractures  of  the  arm  (of  the  humerus)  at  or  near  the  elbow  joint 
or  shoulder  joint  are  frequently  very  difficult  to  make  out,  even  by 
the  most  skillful  surgeon,  especially  if  some  time  has  elapsed  since 
the  injury  was  received;  and  the  treatment  of  necessity  is  equally 
difficult. 

If  near  or  at  the  elbow  joint,  and  if  there  is  much  pain,  heat,  and 
swelling,  as  is  apt  to  be  the  case,  cold  applications  should  be  applied, 
and  the  arm  laid  upon  a  pillow  until  the  swelling  has  gone  down.  A 


FIG.  9. 

Fig.  7  is  the  outside  splint  to  extend  from  shoulder  to  elbow ;  Fig.  8  is  the  internal 
angular  splint  to  be  placed  between  the  arm  and  the  body  ;  and  Fig.  9  shows  the  two 
splints  applied  with  a  bandage  around  them  and  the  arm  from  the  fingers  to  the 
shoulder,  with  a  sling  properly  arranged  to  support  the  forearm  but  not  to  raise  the 
elbow. 

rectangular  splint  of  binder's  board  or  leather  should  then  be  dipped 
in  hot  water  and  applied  to  the  inner  side  of  the  arm  and  forearm. 
The  splint  should  be  wide  enough  to  extend  nearly  halfway  around 
the  arm.  It  must  be  Avell  padded  and  held  in  place  by  a  roller  ban- 
dange,  and  the  forearm  supported  by  a  sling. 

Fracture  of  the  humerus  near  the  shoulder  joint  may  be  treated  by 
means  of  a  shoulder  cap  of  thick  pasteboard  molded  to  fit  the  shoul- 
der and  extending  nearly  to  the  elbow,  or  a  splint  on  the  outer  side 
of  the  arm*,  and  a  pad  of  folded  lint  or  of  absorbent  cotton  under  the 
arm  (in  the  armpit).  The  shoulder  cap  or  splint  should  be  padded 


65 

the  same  as  in  any  other  fracture  and  the  whole  surrounded  by  a 
roller  bandage  which  encircles  the  chest,  binding  the  arm  to  the  chest. 
If  the  deformity  is  marked,  a  second  and  shorter  splint  may  be  placed 
on  the  inner  side  of  the  arm,  taking  care  that  the  upper  end  does 
not  press  too  hard  into  the  armpit.  The  arm  should  then  be  bound 
to  the  chest  by  a  board  bandage. 

After  the  application  of  any  apparatus  for  fracture  of  the  arm  or 
forearm,  the  circulation  should  be  carefully  watched  by  feeling  the 
pulse  at  the  wrist.  If  it  can  not  be  felt,  or  if  the  fingers  swell,  the 
bandages  should  be  removed  and  reapplied  less  tightly. 

FRACTURE    OF    THE    THIGH. 

The  thigh  bone  (femur)  extends  from  the  hip  to  the  knee.  Frac- 
ture of  this  bone  may  occur  in  any  portion  of  the  shaft,  but  the  most 
common  seat  of  fracture  is  about  the  -middle  or  the  middle  third. 
Fractures  high  up  near  the  hip  joint  are  frequently  very  difficult  to 
make  out,  and  the  results  of  treatment  in  such  cases,  even  under  the 
care  of  skillful  surgeons,  are  not  always  satisfactory. 

In  fracture  of  the  middle  or  middle  third  of  the  bone,  the  deform- 
ity is  usually  produced  by  the  lower  fragment  (the  broken  end  of 
the  lower  portion  of  the  bone)  being  drawn  up  behind  and  to  the 
inner  side  of  the  upper  fragment ;  the  weight  of  the  limb  then  causes 
rotation  and  the  foot  and  toes  are  turned  outward. 

If  the  fracture  is  a  little  higher  up,  displacement  is  shown  by  the 
upper  fragment,  which,  by  the  action  of  the  muscles,  is  thrown 
strongly  forward  and  outward.  In  either  case  there  are  complete 
loss  of  power,  shortening  to  the  extent  of  1  to  2  or  3  inches/ pain  on 
the  slightest  movement,  crepitns  (grating)  if  the  broken  ends  of  the 
bone  are  rubbed  together,  and  abnormal  motion. 

In  impacted  fractures,  which  are  met  chiefly  at  or  near  the  hip 
joint,  the  shortening  may  be,  and  usually  is,  less  marked.  Loss  of 
power  is  usually  complete,  but  not  always.  Patients  have  been 
known  to  stand  and  even  walk  a  few  steps.  Injuries  of  this  kind 
require  the  greatest  care ;  the  limbs  should  be  handled  very  caref  ully. 
If  on  slight  traction  or  manipulation  crepitus  is  not  felt,  no  further 
attempt  should  be  made  to  obtain  this  symptom,  for  in  doing  so  the 
impacted  bones  may  be  pulled  apart,  which  is  to  be  avoided  unless 
especially  directed  by  a  skillful  surgeon. 

Treatment. — About  all  the  master  of  the  vessel  may  reasonably  be 
expected  to  do  in  impacted  fracture  is  to  apply  a  broad  bandage 
around  the  hips  and  place  the  patient  in  a  good  bed  on  a  firm  mat- 
tress and*  make  lateral  support  by  means  of  sand  bags,  one  on  the 
outside  long  enough  to  reach  from  the  upper  end  of  the  hip  bone  to 
the  foot,  the  other  along  the  inner  side  of  the  leg  from  the  crotch  to 
13256—04  M 5 


66 

the  foot.  Fill  the  bags  three-quarters  full  of  dry  sand.  Keep  the 
leg  straight,  toes  upward. 

Treatment  of  nonimpacted  fracture  of  the  thigh  bone  at  or  near 
the  hip  joint. — Apply  a  broad  bandage  around  the  hips  and  place 
both  legs  on  the  double-inclined  plane  (fig.  10) ,  or  make  extension  and 
fix  the  limb  in  the  straight  position  by  means  of  a  long  splint  (a 
splint  extending  from  the  armpit  to  the  foot) ,  or  by  the  weight  and 
pulley,  or  by  the  long  splint  and  the  weight  and  pulley  combined, 
in  the  manner  now  about  to  be  explained  in  connection  with  the 

Treatment  of  fractures  of  the  shaft  of  the  thigh  bone. — In  frac- 
ture of  the  shaft  of  this  bone  the  signs  and  symptoms,  as  already 


FIG.  10. — Shows  a  double  inclined  plane — A  and  B  are  hinges,  C  indicates  four  cleats. 


FIG.  11. — Shows  the  same  in  use  with  the  weight  and  pulley — 1  is  the  double  inclined 
plane,  2  and  3  are  circular  pieces  of  adhesive  plaster  to  prevent  4.  the  longitudinal 
strip  on  each  side  of  the  thigh,  from  slipping;  5  and  6  are  the  pulley  and  weight. 

stated,  are  usually  well  marked.  If  the  fracture  is  at  the  upper  end 
or  in  the  upper  third  of  the  bone,  especially  if  the  upper  fragment  is 
tilted  forward,  the  double-inclined  plane  (fig.  11)  well  padded  or 
covered  with  pillows,  with  weight  and  pulle}^  attached  by  means  of 
adhesive  plaster  stuck  to  each  side  of  the  thigh  as  far  as  the  knee, 
affords  the  easiest  and  probably  the  best  means  of  treatment.  But 
in  the  majority  of  cases  when  the  fracture  is  farther  down,  about  the 
middle  or  in  the  middle  third  of  the  bone,  the  weight  and  pulley  with 


67 

the  leg  and  thigh  in  a  straight  line  (fig.  12),  or  the  weight  and  pul- 
ley and  long  splint  combined  (fig.  13),  are  better  adapted  if  properly 
applied.  Sand  bags  may  also  be  used  in  connection  with  any  of  the 
straight  splints  placed  alongside.  In  all  cases  the  fracture  should  be 


FIG.  12. 

Fig.   12  shows  the  weight  and   pulley  applied   with   the  leg  and   thigh   in   the  straight 
position — the  adhesive  strips  being  attached  to  the  leg  as  well  as  the  thigh. 


FIG.  13. 

Fig.  13  shows  the  long  lateral  splint  extending  from  the  armpit  to  a  point  a  little 
helow  the  foot.  It  is  bandaged  to  the  body  and  the  lower  extremity,  and  may  be 
used  with  the  weight  and  pulley. 


Fro.  14. 

Fig.  14  shows  a  fractured  thigh  on  a  double-inclined  plane  with  three  short  splints  ap- 
plied and  held  in  place  by  three  strips  of  adhesive  plaster.  A  shows  two  of  the  three 
splints — the  third  one  being  on  the  inner  side.  B  indicates  three  strips  of  adhesive 
plaster. 

reduced  by  gradually  pulling  and  carefully  pressing  the  broken  bones 
into  their  natural  position.  In  addition  to  the  splints  already  men- 
tioned, short  splints  of  narrow  strips  of  thin  board  or  binder's  board 
should  be  applied  directly  over  the  seat  of  fracture.  (Fig.  14.) 


68 

If  a  double-inclined  plane  (fig.  10)  is  not  at  hand,  two  broad  pieces 
of  board  may  be  nailed  together  at  a  suitable  angle  and  used  instead, 
always  properly  padded  or  covered  with  pillows. 

The  weight  and  pulley  (figs.  12  and  15). — The  weight  and  pulley 
are  applied  as  follows:  Measure  the  distance  from  1  inch  below  the 
crotch  to  a  point  4  inches  below  the  foot.  Cut  a  strip  of  adhesive 
plaster  exactly  twice  as  long  as  the  distance  just  measured  and  3 
inches  wide,  and  stretch  it  on  a  table  or  on  the  floor,  with  the 
sticky  side  up.  Get  a  block  of  wood  4  inches  long,  about  3  inches 
wide,  and  about  \  inch  thick,  with  a  hole  bored  through  the  center 
large  enough  to  admit  a  large  cord.  Place  the  block  exactly  in 
the  center  of  the  long  strip  of  adhesive  plaster.  Cut  another  strip 
of  plaster  the  width  of  the  first  and  18  inches  long,  and  place  it 
on  the  first  strip,  sticky  surfaces  together,  so  as  to  include  the  block 
between  the  center  of  each.  Thus  a  stirrup  is  made  and  the  plaster 
kept  from  sticking  to  the  ankle  bones,  because  it  would  make  them 


o 

FIG.  15. 

A  shows  the  long  strip  of  adhesive  plaster  ;  B  shows  the  short  strip.  C  is  the  hlock  of 
wood  4  x  3  x  |  inches  with  a  hole  in  the  center.  D  shows  the  block  placed  between  the 
two  strips  of  plaster,  all  ready  for  application  to  the  leg  or  thigh. 

sore.  The  long  strip  of  plaster  on  each  side  of  the  stirrup  is  then 
applied  to  the  leg  and  thigh  after  shaving  on  each  side  the  surface 
to  which  it  is  to  be  applied,  extending  from  a  point  just  above  the 
ankle  bone  to  a  point  about  1  inch  below  the  crotch  on  the  inner 
side  and  to  the  same  level  on  the  outer  side,  being  careful  to  keep  the 
block  square  when  the  two  ends  of  the  plaster  are  stuck  to  the  limb. 
A  roller  bandage  is  then  applied  over  the  plaster  from  the  ankle 
up.  A  strong  cord  is  then  passed  through  the  hole  in  the  block 
and  knotted  so  that  it  can  not  slip  through,  the  other  end  being 
passed  over  a  pulley  attached  to  the  foot  of  the  bed  or  elsewhere,  as 
may  be  convenient,  on  a  line  with  the  extended  limb,  and  a  weight 
of  from  5  to  30  pounds,  as  may  be  necessary  or  comfortable  to  the 
patient,  gradually  increased,  attached.  The  same  kind  of  appa- 
ratus may  be  used  with  the  double-inclined  plane,  except  that  the 
plaster  is  applied  only  to  the  thigh,  the  stirrup  coming  just  below 
the  bent  knee. 


69 

Counter  extension  may  be  obtained  by  raising  the  foot  end  of  the 
bed  on  blocks  4  to  G  inches  high.  The  short  splints  should  be  well 
padded  and  extend  well  above  and  below  the  fracture,  and  be  held 
in  place  by  strips  of  plaster  or  bandage. 

The  long  splint  gives  additional  support  and  prevents  outward 
rotation  of  the  leg.  It  should  be  well  padded,  and  have  a- cross- 
piece  at  the  lower  end  to  keep  it  in  position.  Treatment  will  be 
required  for  a  period  of  eight  to  ten  weeks,  but  the  extension  may 
be  lessened  about  the  end  of  the  sixth  week  and  passive  motion  made 
at  the  knee  joint. 

FRACTURE   OF   THE    KNEECAP. 

Fracture  of  the  kneecap  may  be  transverse,  vertical,  or  oblique. 
The  bone  may  be  broken  into  two  or  more  irregularly  shaped  pieces. 

Symptoms  and  signs. — Loss  of  poiuer,  inability  to  extend  the 
joint  or  raise  the  limb  from  the  bed.  In  the  transverse  variety  the 


FIG.  16. 

Fig.  16  shows  a  splint  and  bandage  applied  for  fracture  of  the  knee  cap.  A  is  a  notch 
in  the  board  to  prevent  slipping  of  the  bandage.  B  is  the  end  of  a  bandage  which  is 
to  be  carried  above  the  knee  over  the  bandage  shown  at  A. 

fragments  are  widely  separated.  If  seen  soon  after  the  accident, 
the  line  of  fracture — the  gap  between  the  fragments — may  be  seen 
and  felt.  Swelling  rapidly  appears  and  the  signs  are  obscured. 

Treatment. — Various  forms  of  apparatus  are  employed,  and  in  hos- 
pital practice  the  injury  is  frequently  treated  by  surgical  operation, 
with  good  result.  The  simplest  form  of  treatment  is  to  place  the 
limb  on  a  long  posterior  splint  (fig.  16)  with  the  foot  raised  so  as 
to  relax  the  thigh  muscles,  or  if  the  patient  is  propped  up  in  bed  by 
pillows  or  a  back  rest,  the  limb  may  be  allowed  to  lie  on  a  level. 

Apply  iced  water  or  the  ice  bag  for  a  few  days,  until  the  swelling 
and  heat  have  subsided;  then  remove  the  splint  and  apply  a  roller 
bandage  from  the  foot  to  upper  end  of  thigh.  The  turns  of  the 
bandage  below  and  above  the  knee  should  be  made  in  an  oblique 


70 

direction,  figure-of-eight  fashion,  so  as  to  press  and  hold  the  frag- 
ments of  bone  together;  the  indications  being,  as  in  other  fractures, 
to  restore  the  broken  ends  of  the  bone  to  their  natural  position  and 
keep  them  there.  A  pad  of  cotton  should  be  placed  in  the  hollow 
back  of  the  knee  and  another  smaller  pad  on  the  front  of  the  thigh 
above  the  upper  fragment  before  the  bandage  is  applied.  The  splint 
should  then  be  relined  with  layers  of  dry  cotton  or  folds  of  lint  and 
the  limb  placed  upon  it  as  before,  secured  by  another  roller  bandage. 
If  swelling  or  numbness  of  the  foot  is  complained  of,  the  bandage  is 
too  tight,  and  must  be  removed. 

If  the  bandages  become  loose,  as  they  are  apt  to  do  every  few 
days,  they  should  be  reapplied. 

The  long  splint  should  be  worn  about  six  weeks  or  two  months, 
when  it  may  be  replaced  by  a  shorter  molded  splint  of  leather,  felt, 
or  pasteboard  to  prevent  motion  at  the  joint  when  the  patient  may 
be  allowed  to  wralk  with  canes  or  crutches.  The  short  splint  should 
be  worn  for  at  least  a  month,  and  then  a  suitably  constructed  knee 
cap  should  be  worn  for  one  year  to  support  the  joint.  More  or  less 
stiffness  of  the  joint  is  to  be  expected. 

FRACTURE  OF  THE  LEG   (BETWEEN  THE  KNEE  AND  ANKLE). 

The  leg  extends  from  the  knee  to  the  ankle  and  has  two  bones, 
tibia  and  fibula. 

Fracture  of  the  leg  may  be  simple  or  compound.  Both  bones  may 
be  broken  or  only  one;  the  line  of  fracture  may  be  oblique  or  trans- 
verse. When  both  bones  are  broken  at  the  middle  or  lower  third 
the  deformity  is  usually  quite  marked.  The  break  is  apt  to  be  in  an 
oblique  direction  and  at  a  lower  level  in  the  tibia  (the  shin)  than  in 
the  fibula.  In  simple  fracture  of  the  upper  part  of  the  leg  the  de- 
formity may  be  less  marked,  but  if  the  knee  is  involved  there  may  be 
great  swelling  because  of  acute  and  serious  inflammation  of  the 
joint. 

When  the  shaft  of  only  one  bone  (the  tibia  or  fibula)  is  broken 
there  is  not  much  displacement  because  in  such  case  the  sound  bone 
acts  as  a  side  splint.  Fracture  at  the  lower  end  of  the  tibia  at  the 
projection  on  inner  side  of  ankle  is  sometimes  mistaken  for  sprained 
ankle,  and  if  the  small  fragment  of  bone  is  not  accurately  adjusted 
and  kept  in  proper  position  the  result  may  be  a  weak  and  stiff  joint. 

The  fibula  may  be  fractured  at  any  point,  but  the  important  frac- 
ture of  this  bone  is  known  as  "  Pott's  "  fracture.  (Figs.  17  and  18.) 
This  fracture  occurs  about  3  inches  above  the  ankle,  on  outer  side  of 
the  leg,  and  is  accompanied  or  complicated  by  outward  dislocation  of 
the"  foot,  and  not  infrequently  by  the  breaking  or  tearing  off  of  the 
tip  of  the  lower  end  of  the  tibia. 


71 

Treatment. — If  the  line  of  fracture  is  oblique,  the  limb  must  be 
handled  very  carefully  so  as  to  prevent  injury  to  the  soft  parts  by  the 
sharp  ends  of  the  bone  and  thus  avoid  the  conversion  of  a  simple 
fracture  into  a  compound  one. 

A  Pott's  fracture  should  be  treated  as  follows :  Take  a  board  splint 


FIG.  17. — Shows  the  appearance  of  the  right  foot  after  a  "  Pott's  fracture." 

long  enough  to  extend  from  the  knee  to  a  few  inches  beyond  the  sole 
of  the  foot.  Pad  the  splint  well,  having  the  lower  end  of  the  pad- 
ding at  least  2  inches  thick,  and  do  not  let  it  extend  quite  to  the  ankle 
joint  below.  Apply  the  splint  to  the  inner  side  of  the  leg  so  that  the 
foot  and  ankle  project  below  the  padding.  The  foot  and  leg  are 


FIG.  18. — Shows  on  the  skeleton  the  point  of  fracture  in  the  small  bone  of  the  leg  and 
the  outward  displacement  of  the  bones  of  the  foot. 


then  bandaged  to  the  splint  in  such  a  way  as  to  turn  the  foot  inward 
and  thus  correct  the  outward  displacement.     (Fig.  19.) 

In  all  ordinary  cases  of  simple  fracture  of  the  leg  the  master  of  the 
vessel  can  probably  do  no  better  than  to  place  the  leg  in  a  fracture 


FIG.  19. — Shows  the  splint  applied  for  a  "  Pott's  fracture."  A  shows  the  thick  padding 
(3  inches)  ending  just  above  the  ankle.  The  bandage  B  keeps  the  foot  turned  in  and 
prevents  the  tendency  to  outward  displacement. 

box  (fig.  20)  containing  a  soft  pillow,  and  if  necessary  an  extra  pad 
of  cotton  or  oakum  for  the  heel.  The  side  pieces  of  the  fracture 
box  are  fastened  each  by  two  hinges  to  the  backboard  so  as  to  be  easily 
opened  or  closed.  A  pillow  is  placed  on  the  backboard  and  after 


72 

the  fracture  is  reduced,  by  extension  and  counter  extension,  the  leg  is 
carefully  placed  upon  the  pillow  and  the  sides  of  the  box  are  closed 
or  drawn  together  closely  enough  to  make  easy  and  equable  support 
to  the  broken  bones.  Two  or  three  holes  should  be  bored  in  the  upper 
edge  of  the  sideboards  so  that  they  may  be  tied  together,  or  strips  of 
bandage  may  be  tied  around  the  box.  Two  mortise  holds  should  be 
made  in  the  footboard  for  the  reception  of  strips  of  adhesive  plaster, 
so  that  in  addition  to  the  fracture  box  the  weight  and  pulley  may  be 
applied  to  overcome  any  shortening  or  deformity.  Another  good 
plan  is  to  line  the  backboard  (the  bottom  of  the  box)  with  a  layer  of 
cotton  or  folds  of  lint  and  then  fill  in  and  surround  the  leg  with  bran. 
In  the  absence  of  any  of  the  apparatus  mentioned,  three  well- 
padded  splints  may  be  applied — one  on  each  side  and  one  on  the  back 
of  the  leg.  But  if  there  is  any  displacement  or  overriding  the  frac- 
ture must  be  reduced  and  held  in  proper  position  while  the  splints 
are  being  applied. 


PIG.  20. 

Whatever  form  of  appliance  is  adopted  care  must  be  taken  that  the 
foot  is  at  a  right  angle  with  the  leg,  the  toes  pointing  directly  upward. 
The  inner  side  of  the  kneecap,  the  projection  on  the  inner  side  of  the 
ankle,  and  the  inner  side  of  the  big  toe  should  be  on  the  same  line. 

In  the  hospital,  or  where  the  patient  is  under  the  care  of  a  surgeon, 
a  fixed  dressing  of  plaster  of  Paris,  or  silicate  of  soda,  may  be  used 
to  the  greatest  advantage  after  the  first  week,  or,  in  some  cases,  from 
the  very  beginning  of  treatment. 

COMPOUND    FRACTURES. 

Compound  fractures  are  serious  accidents  and  require  prompt 
attention.  The  general  principles  of  treatment  so  far  as  the  bone 
is  concerned  (place  it  in  normal  position  and  keep  it  there)  are  the 
same  as  for  simple  fracture.  But  to  do  this  and  at  the  same  time 
give  proper  attention  to  the  wound  in  the  soft  parts  (the  open  wound 
extending  down  to  the  bone)  frequently  demands  the  highest  surgical 
skill. 

Shock  from  loss  of  blood  is  the  immediate  danger.  Inflammation, 
erysipelas,  blood  poisoning,  or  lockjaw  may  set  in  later,  and  still 
later  the  patient  may  become  exhausted  from  long-continued  suppu- 
ration. 


73 

Treatment. — If  the  wound  is  very  small  it  should  be  well  cleaned 
with  hot  water  (water  that  has  been  raised  to  the  boiling  point  and 
allowed  to  cool  down  to  about  120°)  or  by  antiseptic  solution  (sol. 
bichloride  mercury  1  to  5,000),  then  covered  with  antiseptic  gauze, 
and  the  case  treated  as  a  simple  fracture. 

In  nearly  all  cases,  however,  the  safest  and  best  plan  is  to  leave 
the  wound  uncovered  by  splint  or  bandage,  so  that  light  dressings 
may  be  easily  applied  and  frequently  changed.  The  wound  should 
be  thoroughly  cleansed  with  hot  water  and  antiseptic  solution,  and, 
after  reducing  the  fracture,  the  splints,  or  extending  apparatus, 
should  be  so  arranged  that  the  wound  is  freely  accessible  and  easily 
drained.  Strips  of  antiseptic  gauze  should  be  placed  in  the  wound 
and  gently  carried  down  to  the  bottom  by  means  of  a  probe,  and  a 
larger  piece  of  gauze  in  loose  folds  should  be  laid  over  the  wound. 

The  gauze  dressing  should  be  renewed  every  day  or  every  second 
day,  or  as  often  as  necessary  to  keep  the  wound  well  drained  until 
it  heals  from  the  bottom. 

In  severe  cases  amputation  may  be  necessary  to  save  life,  and  in 
all  cases  the  patient  should  be  placed  under  the  care  of  a  surgeon  as 
soon  as  possible. 

DISLOCATIONS. 

A  bone  is  dislocated  or  "  out  of  joint "  when  it  is  displaced  or 
forcibly  separated  from  another  bone  entering  into  the  composition 
of  a  joint. 

Dislocations  may  be  complete  or  incomplete.  A  dislocation  is 
complete  when  the  articular  surfaces  are  entirely  separated  and  the 
ligaments  torn,  as  in  dislocation  of  the  hip  joint;  incomplete  when 
the  articular  surfaces  are  not  entirely  displaced.  Dislocations  may 
be  simple,  compound,  or  complicated. 

A  dislocation  is  simple  when  there  is  no  wound  of  the  skin  and  soft 
parts — when  the  articular  surfaces  are  not  exposed  to  the  outer  air; 
compound  when  there  is  an  open  wound  and  the  outer  air  is  brought 
into  contact  with  the  articular  surfaces  of  the  joint;  complicated 
when  besides  the  dislocation  there  is  a  fracture  and  serious  damage 
to  the  soft  parts,  or  to  blood  vessels  or  nerves. 

Dislocations  are  said  to  be  most  common  in  adult  or  middle  life, 
when  the  bones  are  strong  and  the  muscles  powerful.  In  the  young 
and  old  the  boires  are  more  apt  to  break.  There  are,  however,  strik- 
ing exceptions  to  this  rule  when  applied  to  the  elbow  joint  and  the 
shoulder  joint.  The  elbow  joint  in  young  subjects  is  frequently  dis- 
located; and  dislocation  of  the  shoulder  joint  in  old  men  is  not 
uncommon. 

Symptoms  and  signs  of  dislocations. — Deformity  is  always  present 
and  may  be  determined  by  comparing  the  injured  side  with  the 


74 

sound  side.  The  head  or  end  of  the  bone  is  in  an  abnormal  position;" 
the  attitude  of  the  limb  is  changed;  the  patient  can  not  move  the 
limb;  and  when  the  surgeon  or  the  master  tries  to  move  the  joint  he 
finds  it  very  stiff.  There  may  be  shortening  or  lengthening.  For 
example,  in  dislocation  of  the  hip  the  head  of  the  thigh  bone  may  be 
thrown  outward  and  upward,  when  there  will  be  shortening  of  the 
leg ;  or  it  may  be  forced  downward  and  inward,  when  the  length  of  the 
limb  will  be  increased. 

Treatment. — The  indications  are  to  replace  the  bones  in  their 
natural  position  and  to  keep  the  parts  at  rest  until  the  ligaments  and 
damaged  tissues  about  the  joint  are  healed.  A  dislocation  should  be 
reduced  immediately  after  the  accident,  whilst  the  patient  is  faint  and 
the  muscles  are  in  a  relaxed  condition. 

Having  thus  briefly  described  a  dislocation  and  the  treatment  indi- 
cated, the  question  now  arises,  How  shall  the  treatment  be  applied, 
how  shall  the  dislocation  be  reduced  ?  And  when  it  is  taken  into  con- 
sideration that  the  reduction  of  dislocations  not  infrequently  taxes 
the  skill  of  the  most  experienced  surgeon  (even  with  the  aid  of  gen- 
eral anesthetics),  it  is  hardly  to  be  expected  that  a  nonprofessional 
man  will  be  able  to  accomplish  the  desired  results  in  many  cases.  It 
must  also  be  borne  in  mind  that  there  are  certain  dangers  attending 
efforts  at  reduction,  especially  at  the  larger  joints,  if  improperly  or 
too  forcibly  applied — such  as  fracture  of  bone  or  rupture  of  blood 
vessel. 

DISLOCATION  OF   THE    FINGERS. 

Dislocation  of  the  bones  of  the  fingers  may  be  backward  or 
forward. 

Treatment. — Extension  and  counter  extension  and  manipulation. 
Pull  the  finger  directly  in  line  with  the  hand,  and  when  fully  extended 
make  pressure  on  the  head  of  the  bone.  Reduction  is  usually  effected 
without  much  difficulty.  Place  the  finger  on  a  well-padded  splint 
for  one  week,  then  make  passive  motion,  and,  if  necessary,  the  splint 
may  be  worn  for  another  week. 

DISLOCATION   OF   THE    THUMB. 

Dislocation  of  the  thumb  may  be  backward  or  forward. 

Treatment. — The  treatment  is  not  the  same  as  for  dislocation  of 
the  fingers,  and  reduction,  especially  of  the  backward  dislocation,  is 
usually  very  difficult.  Try  by  pushing  the  end  of  the  thumb  upward 
and  backward  until  it  stands  perpendicularly  on  the  bone  from  which 
it  is  dislocated  (fig.  21),  then  make  strong  pressure  against  the  base 
of  the  dislocated  bone  from  behind  forward,  sliding  it  on  the  bone 
beneath  till  it  gets  to  the  end,  then  flex  or  bend  the  thumb  into  place. 
(Fig.  22.) 


75 


DISLOCATION    OF    THE    WRIST. 

Dislocation  of  the  wrist  joint  may  be  backward  or  forward.  It  is 
a  rare  injury.  Fracture  about  the  wrist  is  more  common,  and  is 
sometimes  mistaken  for  dislocation.  A  stiff  joint  is  apt  to  be  the 
result. 

Treatment. — Extension,  counter  extension,  and  direct  pressure. 
Grasp  the  hand  of  the  patient,  pull  in  a  straight  line,  and  have  an 
assistant  pull  on  the  forearm  in  the  opposite  direction,  and  when  the 
parts  are  fully  extended  make  direct  pressure  upon  the  wrist  bones. 
Apply  a  bandage,  and  place  the  hand  and  forearm  on  a  well-padded 
splint  for  a  week ;  then  remove  the  splint  and  make  passive  motion  at 


FIG.  21. 


FIG.  22. 


Pig.  21  shows  a  backward  dislocation  of  the  right  thumb.  A.  is  the  head  of  the  bone 
in  the  hand  and  B  is  the  bone  in  the  thumb  which  has  slipped  backward  and  rests  on 
the  first  bone  below  or  behind  its  head.  Fig.  22  shows  how  to  replace  it.  The  thumb 
should  be  brought  out  perpendicular  to  the  hand  (see  arrow  A)  and  its  base  pushed 
forward  (see  arrow  B)  till  it  reaches  the  end  of  the  first  bone,  then  it  should  be  bent 
into  the  palm  of  the  hand.  Fig.  22  shows  the  bone  in  the  proper  position  for  bending. 

the  joint ;  reapply  the  splint  and  remove  it  after  an  interval  of  another 
week.  If  there  is  much  pain  or  swelling  after  reduction  of  the  dislo- 
cation, apply  cold  water  or  lead-opium  wash. 

DISLOCATION   OF   THE   ELBOW. 

Dislocations  of  the  elbow  are  serious  accidents.  They  present  a 
variety  of  forms,  backward,  forward,  outward,  and  inward,  and  these 
are  divided  into  a  number  of  subvarieties.  One  or  both  bones  may  be 


76 

involved,  and  the  dislocation  may  be  associated  with  fracture.  Re- 
duction in  some  cases  is  comparatively  easy,  in  others  it  is  very  diffi- 
cult, even  in  the  hands  of  experienced  surgeons. 

Without  a  thorough  knowledge  of  the  anatomy  of  the  normal  joint 
it  is  very  difficult  to  understand  the  different  forms  of  dislocation,  and 
of  necessity  equally  difficult  to  apply  the  proper  treatment. 

Immediately  after  the  accident  and  before  swelling  sets  in  the 
injured  elbow  should  be  carefully  compared  with  the  sound  one. 
When  the  normal  arm  is  extended  (straight)  the  tip  of  the  elbow  and 
the  bony  points  on  either  side  should  be  in  a  transverse  line  across  the 
joint.  If  these  prominences  are  found  out  of  line,  dislocation  or  frac- 
ture is  probably  present. 


FIG.  23. 
Dislocation  of  the  shoulder. 

Treatment. — Fixation  of  the  arm  above  the  elbow,  extension  or 
flexion  of  the  forearm,  and  direct  pressure  by  means  of  the  thumbs  or 
fingers  on  the  head  of  the  dislocated  bone,  so  as  to  push  it  back  into  the 
socket.  After  reduction  an  angular  splint  should  be  applied  to  inner 
side  of  arm  (fig.  8),  lightly  bandaged,  and  the  forearm  carried  in  a 
sling.  Cold  water  or  lead-opium  wash  may  be  applied  to  reduce 
inflammatory  action.  Passive  motion  should  be  employed  at  the  end 
of  a  week. 


77 

DISLOCATION    OF    THE    SHOULDER. 

[After  Helfrich.] 

Dislocation  of  the  shoulder  joint  is  a  very  common  accident.  It 
occurs  as  frequently  as  all  other  dislocations  put  together.  The  fre- 
quency is  explained  by  the  great  latitude  of  motion  of  the  joint,  the 
shallowness  of  the  socket,  and  the  size  and  rounded  shape  of  the  head 
of  the  bone,  the  laxity  of  the  capsular  ligament,  and  the  leverage 
exerted  on  the  joint  by  the  long  bone. 

There  are  three  chief  forms  of  dislocation  of  the  shoulder,  (1)  for- 
ward and  downward  below  the  collar  bone,  (2)  directly  downward 
into  the  armpit,  and  (3)  backward  on  the  shoulder  blade. 

The  symptoms  and  signs  are  pain,  swelling,  rigidity  (stiffness), 
loss  of  power,  flattening  and  angular  appearance  of  the  shoulder  as 
compared  with  the  other  shoulder,  abnormal  situation  of  the  head  of 
the  bones,  and  change  in  the  axis  of  the  long  bone.  (Fig.  23.)  In 
the  first  variety,  the  most  common  of  all,  the  head  of  the  bone  may 
be  felt  in  front  of  the  armpit  and  below  the  collar  bone,  and  the  elbow 
points  outward  and  backward.  In  the  second  the  head  of  the  bone 
may  be  felt  in  the  armpit,  and  the  elbow  points  outward.  In  the 
third,  the  head  of  the  bone  may  be  felt  on  the  back  of  the  shoulder 
blade,  the  elbow  points  forward,  and  the  forearm  is  thrown  across 
the  chest.  Another  valuable  sign  is  that  when  the  elbow  is  placed  on 
the  chest  the  patient  can  not  place  the  hand  of  the  injured  side  upon 
the  opposite  shoulder,  or  if  the  hand  is  placed  on  the  shoulder  the 
elbow  can  not  be  brought  into  contact  with  the  chest. 

Treatment. — The  treatment  for  the  first  variety  (forward  and 
downward)  is  as  follows:  Lay  the  patient  down  or  let  him  sit  on  a 
chair;  bend  the  forearm  on  the  arm;  press  the  elbow  against  the 
side  of  the  chest  and  hold  it  there ;  rotate  the  arm  outward  by  carry- 
ing the  forearm  outward ;  pull  steadily  on  the  arm  and  rotate  inward 
by  carrying  the  elbow  upward  and  forward  with  forearm  across  the 
chest.  While  this  is  going  on  have  an  assistant  place  his  hand  in 
the  armpit  and  press  the  head  of  the  bone  into  place. 

For  the  second  variety  (directly  downward  into  the  armpit),  place 
the  patient  on  his  back;  remove  your  boot;  place  your  heel  in  the 
armpit ;  grasp  the  wrist  and  pull  steadily  on  the  arm.  If  the  dislo- 
cation is  in  the  right  shoulder,  seat  yourself  on  the  right  side  of  the 
patient  and  use  your  right  foot;  and  if  the  injury  is  in  the  left 
shoulder,  seat  yourself  on  the  left  side  and  use  your  left  foot.  The 
same  principles  may  be  carried  out  by  seating  the  patient  on  a  low 
chair  and  placing  your  knee  in  the  armpit. 

Another  method  is  to  have  an  assistant  stand  upon  a  table  and 
make  counter  extension  with  a  towel,  or  a  strong  piece  of  soft  cloth 
of  any  kind,  passed  under  the  armpit  of  the  patient,  while  the  oper- 


78 

ator  pulls  the  arm  downward.  The  same  method  may  be  employed 
by  causing  the  patient  to  lie  on  his  back,  and  an  additional  advantage 
may  be  obtained  by  placing  a  rolled  bandage  or  a  pad  of  any  kind  in 
the  folds  of  a  towel  in  the  armpit. 

In  dislocation  backward  on  the  shoulder  blade,  pull  the  arm  for- 
ward and  make  direct  pressure  forward  on  the  head  of  the  bone,  or 
stand  behind  the  patient,  draw  the  elbow  backward,  and  with  the 
thumb  press  upon  the  head  of  the  bone  and  guide  it  into  place. 

After  reduction,  a  soft  pad  should  be  placed  in  the  armpit,  the 
upper  arm  bandaged  to  the  body,  and  the  forearm  placed  in  a  sling 
across  the  chest.  Passive  motion  at  the  joint  should  begin  at  the 
end  of  a  week  and  be  repeated  daily,  but  the  arm  should  be  carried 
in  the  sling  about  three  weeks. 

DISLOCATION    OF    THE    COLLAR   BONE. 

The  collar  bone  extends  from  the  upper  border  of  the  breast  bone 
to  the  highest  point  of  the  shoulder  blade.  Dislocation  may  occur 
at  either  end.  Reduction  is  comparatively  easy,  but  it  is  difficult  to 
retain  the  bone  in  position. 

Treatment. — Make  extension  by  drawing  back  the  shoulders,  the 
knee,  if  necessary,  being  placed  between  the  shoulder  blades;  push 
the  end  of  the  bone  in  place,  and  try  to  keep  it  there  by  a  firm  pad, 
fastened  by  adhesive  plaster  and  bandage.  The  best  result  may  be 
obtained  by  placing  the  patient  at  rest  on  his  back  for  three  weeks. 

DISLOCATION    OF   THE    TOES. 

Dislocations  of  the  toes  are  very  rare  accidents.  The  treatment  is 
the  same  as  for  dislocation  of  the  fingers.  Dislocation  of  the  big 
toe  may  be  treated  the  same  as  dislocation  of  the  thumb. 

DISLOCATION    OF    THE    ANKLE. 

The  foot  may  be  dislocated  forward,  backward,  outward,  inward, 
or  upward.  The  dislocation  may  be  complete  or  incomplete. 

The  lower  ends  of  the  bones  of  the  leg  enter  into  the  formation  of 
the  ankle  joint,  the  end  of  the  tibia  on  the  inner  side  and  the  end 
of  the  fibula  on  the  outer  side  of  the  joint.  Dislocations  of  the  ankle 
are  usually  complicated  by  fracture  of  the  tip  of  one  or  both  of  these 
bones;  when,  in  addition,  the  fibula  is  broken  above  the  ankle,  the 
injury  is  known  as  Pott's  fracture,  already  referred  to. 

Treatment. — Extension,  counter  extension  and  pressure.  Flex 
the  leg  on  the  thigh,  and  the  thigh  at  right  angle  to  body;  pull 
steadily  on  the  foot,  while  an  assistant  makes  counter  extension  at 
the  thigh,  and  press  the  bones  in  place.  Apply  cold  water,  or  lead- 
opium  wash,  and  place  the  foot  and  leg  in  a  fracture  box,  or  apply 


well-padded  molded  splints.  Binder's  board  dipped  in  warm  water 
and  molded  to  the  part  and  lined  with  thick  layers  of  cotton  will 
answer  the  purpose.  If  a  Pott's  fracture  use  the  splint  shown  in 
fig.  16.  Make  passive  motion  at  the  joint  at  the  end  of  two  weeks. 

DISLOCATION    OF    THE    KNEE. 

Dislocation  of  the  knee  may  be  complete,  incomplete,  compound, 
or  complicated.  The  direction  of  the  dislocation  may  be  forward, 
backward,  outward,  or  inward.  The  deformity  is  quite  marked. 
Keduction  is  not  very  difficult,  but  the  injury  is  a  serious  one  and 
care  must  be  taken  in  making  reduction  not  to  produce  additional 
damage  by  too  forcible  extension.  Fortunately  the  injury  is  exceed- 
ingly rare. 

Treatment. — Extension,  counter  extension,  and  pressure.  Have  one 
assistant  pull  steadily,  not  too  hard,  on  the  leg  or  ankle,  while  another 
assistant  fixes  or  pulls  on  the  thigh  and  presses  the  bone  into  place. 
After  reduction  apply  cold  water,  or  lead-opium  wash,  and  place 
the  leg  in  a  posterior  straight  splint,  well  padded,  especially  below  the 
hollow  of  the  knee,  and  make  passive  motion  at  the  end  of  two  weeks. 
When  the  patient  begins  to  walk,  a  kneecap  or  flannel  bandage  should 
be  applied. 

DISLOCATION   OF   THE    HIP. 

Dislocation  of  the  hip  joint  is  a  serious  injury.  It  occurs  much  less 
frequently  than  dislocation  of  the  shoulder  joint.  The  socket  of  the 
hip  joint  is  very  deep,  and  the  ligaments  and  muscles  surrounding  the 
joint  are  very  strong  and  powerful.  Dislocation  occurs  only  when 
the  limb  is  in  a  certain  position,  when  its  axis  is  changed  from  that 
of  the  body,  and  when  in  consequence  of  any  sudden  or  great  force 
received  on -the  lower  end  of  the  leg  or  knee  the  head  of  the  bone  is 
forced  through  the  ligament  (the  capsule)  which  surrounds  the  joints. 
The  head  of  the  bone  may  then  be  thrown  (1)  backiuard  and  upward, 
(^backward,  (3)  forward  and  downward,  (4)  forward.  The  dif- 
ferent directions  indicate  the  different  forms  of  dislocation.  The 
first  is  the  most  common. 

In  the  first  form  examination  from  below  up  shows  the  ~big  toe 
turned  toward  or  resting  on  the  instep  of  the  opposite  foot ;  the  knee 
flexed  and  resting  against  thigh  at  upper  margin  of  opposite  knee- 
cap ;  the  thigh  rotated  inward  and  drawn  toward  its  fellow ;  bulging 
of  the  hip ;  and  about  2  inches  shortening  of  the  entire  limb. 

In  the  second  form  the  signs  are  the  same  as  in  the  first,  but  less 
marked.  (Fig.  24.)  Fracture  of  the  neck  of  the  thigh  bone  is 
sometimes  mistaken  for  this  injury.  But  in  fracture  there  is  abnor- 
mal motion,  and  the  foot  is  turned  outward. 

In  the  third  form  (fig.  25)  the  signs  are  almost  exactly  the  reverse 


80 


of  the  first  form.  The  foot  and  knee  are  turned  outward,  the  hip  is 
flattened,  and  the  entire  limb  is  lengthened. 

The  signs  of  the  fourth  form  are  nearly  the  same  as  those  of  the 
third,  except  that  the  entire  limb  is  shortened. 

Treatment. — The  treatment  is  by  manipulation,  or  by  extension 
and  counter  extension. 

For  the  first  and  second  forms  of  dislocation,  above-described  treat- 
ment may  be  applied  as  follows :  Place  the  patient  on  his  back  on  a 
mattress  on  the  floor.  Seize  the  foot  or  ankle  with  one  hand  and 
place  the  other  hand  under  the  knee.  Flex  the  leg  upon  the  back  of 
the  thigh,  and  the  thigh  upon  the  body  to  about  a  right  angle ;  then 
carry  the  knee  inward  and  rotate  it  inward  on  its  own  axis,  then  sud- 
denly raise  it  (lift  it  toward  the  ceiling)  so  that  the  head  of  the  bone 
may  be  thrown  over  the  rim  of  the  socket,  and  immediately  extend 


FIG.  24. 


FIG.  25. 


Fig.  24  shows  a  backward  dislocation  of  the  hip  with  the  knee  and  toe  turned  in  and 
the  heel  raised  and  the  limb  shortened.  Fig.  25  shows  a  forward  and  downward  dis- 
location of  the  right  hip  with  the  knee  and  toe  turned  out  and  the  limb  lengthened. 

the  limb  with  outward  rotation  to  its  normal  position  so  that  the  head 
of  the  bone  may  return  to  the  socket  through  the  hole  in  the  capsule 
by  which  it  escaped.. 

The  treatment  of  the  third  and  fourth  forms  of  injury  corresponds 
to  that  for  the  first  and  second,  except  that  the  limb  should  be  carried 
outward  first,  then  inward,  across  the  median  line,  and  rotated 
inward  on  its  own  axis,  and  then  suddenly  lifted  and  brought  down 
to  its  normal  position  by  the  side  of  its  fellow. 

No  great  force  should  be  used  in  making  these  movements.  If  any 
considerable  resistance  is  met  with  in  rotating  or  lifting  the  bone  the 
movement  should  be  modified  in  such  a  way  that  the  head  of  the  bone 
may  follow  the  path  of  least  resistance. 


81 

If  extension  and  counter  extension  be  applied  they  should  follow 
the  line  of  the  axis  of  the  dislocated  thigh.  It  must  not  be  forgotten 
in  the  consideration  of  these  methods  that  the  application  of  too 
much  force  or  of  force  improperly  applied  may  produce  fracture  of 

the  bone. 

SPRAINS. 

A  sprain  is  a  stretching  or  wrenching  of  a  joint.  The  joints  most 
frequently  affected  are  the  ankle,  wrist,  knee,  and  shoulder. 

The  symptoms  and  signs  are  pain,  swelling,  impairment  or  loss  of 
motion,  and  discoloration  from  effusion  of  blood.  When  there  is 
much  swelling  it  may  be  difficult  to  determine  whether  sprain  or  frac- 
ture, or  both,  are  present. 

Treatment. — If  seen  at  once,  before  there  is  much  swelling,  a 
bandage  should  be  applied  from  the  toes  to  2  or  3  inches  above  the 
ankle,  and  the  joint  should  be  kept  at  perfect  rest  in  an  elevated 
position.  If  much  swelling  has  already  taken  place  apply  cold 
applications  continuously  for  several  hours.  If  the  symptoms  do  not 
rapidly  subside  apply  hot  applications — cloths  or  towels  wrung  out 
of  hot  water  and  frequently  changed.  After  the  swelling  has  gone 
down  a  bandage  properly  applied  will  afford  considerable  benefit. 
(Fig.  26.) 


FIG.  26. 

Fig.  26  shows  the  application  of  adhesive  plaster  to  an  ulcer  of  the  leg  at  A  and  of  an 
ordinary  bandage  from  the  foot  up  the  leg,  B. 

The  joint  must  not  be  kept  too  long  at  rest.     Passive  motion  should 
be  performed  as  soon  as  the  inflammatory  symptoms  have  subsided. 

NOSEBLEED. 

If  bleeding  of  the  nose  occur  in  a  full-blooded  person,  especially 

if  such  person  is  subject  to  dizziness,  we  should  not  be  in  too  much  of 

a  hurry  to  stop  it.     But  if  the  bleeding  is  the  result  of  injury  or  if  it 

occur  in  a  person  suffering  from  disease  of  the  heart  or  lungs  or  from 

13356—04  M 6 


82 

the  effects  of  malarial  fever,  scurvy,  or  any  disease  of  the  general  sys- 
tem, effort  should  be  made  to  stop  it. 

Treatment. — Remove  all  pressure  of  clothing  from  neck  and  chest. 
Caution  patient  not  to  blow  his  nose.  If  too  weak  to  stand,  place 
him  on  his  back  with  his  arms  raised  and  his  head  on  a  high  pillow. 
Bathe  the  nose  in  cold  water,  apply  cold  water  to  back  of  neck  or  an 
ice  bag  to  the  forehead.  Pack  the  nostrils  with  pellets  of  absorbent 
cotton  soaked  in  a  solution  of  alum  or  gelatin.  The  bleeding  is  some- 
times brought  under  control  by  the  application  of  hot  water  to  the 
nostrils. 

In  very  severe  cases  the  posterior  as  well  as  the  anterior  nares 
should  be  plugged.  In  the  absence  of  a  surgeon  the  application  of 
this  method  may  be  attended  with  some  difficulties.  But  if  the 
master  of  the  vessel  decides  to  try  it  he  may  proceed  as  follows: 
Pass  a  fine  string  twine,  about  20  inches  long,  through  the  eye  of  a 
hard  rubber  catheter,  and  thus  armed  pass  the  catheter  along  the 
floor  of  the  nose  to  the  back  of  the  mouth  below  the  soft -palate; 
introduce  a  forceps  into  the  mouth  back  to  the  end  of  the  catheter, 
seize  the  twine,  and  bring  it  out  of  the  mouth.  Then  tie  a  pledget 
of  absorbent  cotton  or  lint  to  the  twine  about  12  inches  from  the 
end  of  it;  then  pull  on  the  catheter  and  the  other  end  of  the  twine 
and  draw  the  pledget  into  the  mouth,  guided  by  the  finger,  behind 
the  soft  palate  into  the  posterior  nares.  He  will  then  have  the 
posterior  nares  plugged,  and  one  end  of  the  twine  hanging  out  at 
the  mouth  and  the  other  end  at  the  nose. 

Secure  the  ends  of  the  twine  by  tying  them  together,  and  allow 
the  plug  to  remain  about  two  days. 

The  pledget  of  cotton  or  lint  should  be  about  an  inch  long  and 
half  an  inch  wide. 

DIRECTIONS   FOR   RESTORING   THE   APPARENTLY   DROWNED. 

As  practiced  in  the  United  States  Life-Saving  Service. 

Note. — These  directions  differ  from  those  given  in  the  last  re- 
vision of  the  Regulations  by  the  addition  of  means  for  securing 
deeper  inspiration.  The  method  heretofore  published,  known  as  the 
Howard,  or  Direct  Method,  has  been  productive  of  excellent  results 
in  the  practice  of  the  Service,  and  is  retained  here.  It  is,  however, 
here  arranged  for  practice  in  combination  with  the  Sylvester  method, 
the  latter  producing  deeper  inspiration  than  any  other  known  method, 
while  the  former  effects  the  most  complete  expiration.  The  com- 
bination, therefore,  tends  to  produce  the  most  rapid  oxygenation  of 
the  blood — the  real  object  to  be  gained.  The  combination  is  prepared 
primarily  for  the  use  of  life-saving  crews  where  assistants  are  at 
hand.  A  modification  of  Rule  III,  however,  is  published  as  a  guide 


83 

in  cases  where  no  assistants  are  at  hand  and  one  person  is  compelled 
to  act  alone.  In  preparing  these  directions  the  able  and  exhaustive 
report  of  Messrs.  J.  Collins  Warren,  M.  D.,  and  George  B.  Shattuck. 
M.  D.,  committee  of  the  Humane  Society  of  Massachusetts,  embraced 
in  the  annual  report  of  the  society  for  1895-96,  has  been  availed  of, 
placing  the  Department  under  many  obligations  to  these  gentlemen 
for  their  valuable  suggestions. 

Rule  I. — Arouse  the  patient. — Do  not  move  the  patient  unless  in 
danger  of  freezing;  instantly  expose  the  face  to  the  air,  toward  the 
wind  if  there  be  any ;  wipe  dry  the  mouth  and  nostrils ;  rip  the  cloth- 
ing so  as  to  expose  the  chest  and  waist;  give  two  or  three  quick, 
smarting  slaps  on  the  chest  with  the  open  hand. 


FIG.  27. 


If  the  patient  does  not  revive,  proceed  immediately  as  follows : 
Rule  II. — To  expel  water  from  the  stomach  and  chest  (see  fig. 
27). — Separate  the  jaws  and  keep  them  apart  by  placing  between  the 
teeth  a  cork  or  small  bit  of  wood ;  turn  the  patient  on  his  face,  a  large 
bundle  of  tightly  rolled  clothing  being  placed  beneath  the  stomach; 
press  heavily  on  the  back  over  it  for  half  a  minute,  or  as  long  as  fluids 
flow  freely  from  the  mouth. 

Rule  III. — To  produce  breathing  (see  figs  28  and  29). — Clear  the 
mouth  and  throat  of  mucus  by  introducing  into  the  throat  the  corner 
of  a  handkerchief  wrapped  closely  around  the  forefinger;  turn  the 
patient  on  the  back,  the  roll  of  clothing  being  so  placed  as  to  raise  the 
pit  of  the  stomach  above  the  level  of  the  rest  of  the  body.  Let  an 
assistant  with  a  handkerchief  or  piece  of  dry  cloth  draw  the  tip  of  the 
tongue  out  of  one  corner  of  the  mouth  (which  prevents  the  tongue 
from  falling  back  and  choking  the  entrance  to  the  windpipe),  and 


.  84 

keep  it  projecting  a  little  beyond  the  lips.  Let  another  assistant 
grasp  the  arms  just  below  the  elbows  and  draw  them  steadily  upward 
by  the  sides  of  the  patient's  head  to  the  ground,  the  hands  nearly 
meeting  (which  enlarges  the  capacity  of  the  chest  and  induces  inspi- 
ration). (Fig.  28.)  While  this  is  being  done  let  a  third  assistant 
take  position  astride  the  patient's  hips  with  his  elbows  resting  upon 
his  own  knees,  his  hands  extended  ready  for  action.  Next,  let  the 
assistant  standing  at  the  head  turn  down  the  patient's  arms  to  the 
sides  of  the  body,  the  assistant  holding  the  tongue  changing  hands  if 
necessary a  to  let  the  arms  pass.  Just  before  the  patient's  hands 


FIG.  28. 

reach  the  ground  the  man  astride  the  body  will  grasp  the  body  with 
his  hands,  the  balls  of  the  thumb  resting  on  either  side  of  the  pit  of 
the  stomach,  the  fingers  falling  into  the  grooves  between  the  short 
ribs.  Now,  using  his  knees  as  a  pivot,  he  will  at  the  moment  the 
patient's  hands  touch  the  ground  throw  (not  too  suddenly)  all  his 
weight  forward  on  his  hands,  and  at  the  same  time  squeeze  the  waist 
between  them,  as  if  he  wished  to  force  anything  in  the  chest  upward 
out  of  the  mouth ;  he  will  deepen  the  pressure  while  he  slowly  counts, 
one,  two,  three,  four  (about  five  seconds),  then  suddenly  let  go  with  a 
final  push,  which  will  spring  him  back  to  his  first  position.6  This 
completes  expiration.  (Fig.  29.) 

At  the  instant  of  his  letting  go,  the  man  at  the  patient's  head  will 
again  draw  the  arms  steadily  upward  to  the  sides  of  the  patient's 
head  as  before  (the  assistant  holding  the  tongue  again  changing  hands 

a  Changing  hands  will  be  found  unnecessary  after  some  practice ;  the  tongue, 
however,  must  not  be  released. 
z»A  child  or  very  delicate  patient  must,  of  course,  be  more  gently  handled, 


85 

to  let  the  arms  pass  if  necessary),  holding  them  there  while  he  slowly 
counts  one,  two,  three,  four  (about  five  seconds). 

Repeat  these  movements  deliberately  and  perseveringly  twelve  to 
fifteen  times  in  every  minute — thus  imitating  the  natural  motions  of 
breathing. 

If  natural  breathing  be  not  restored  after  a  trial  of  the  bellows 
movement  for  the  space  of  about  four  minutes,  then  turn  the  patient 
a  second  time  on  the  stomach,  as  directed  in  Rule  II,  rolling  the  body 
in  the  opposite  direction  from  that  in  which  it  was  first  turned,  for 
the  purpose  of  freeing  the  air  passage  from  any  remaining  water. 
Continue  the  artificial  respiration  from  one  to  four  hours,  or  until  the 
patient  breathes,  according  to  Rule  III;  and  for  a  while,  after  the 
appearance  of  returning  life,  carefully  aid  the  first  short  gasps  until 


FIG.  29. 

deepened  into  full  breaths.  Continue  the  drying  and  rubbing,  which 
should  have  been  unceasingly  practiced  from  the  beginning  by  assist- 
ants, taking  care  not  to  interfere  with  the  means  employed  to  produce 
breathing.  Thus  the  limbs  of  the  patient  should  be  rubbed,  always 
in  an  upward  direction  toward  the  body,  with  firm-grasping  pressure 
and  energy,  using  the  bare  hands,  dry  flannels,  or  handkerchiefs,  and 
continuing  the  friction  under  the  blankets  or  over  the  dry  clothing. 
The  warmth  of  the  body  can  also  be  promoted  by  the  application  of 
hot  flannels  to  the  stomach  and  armpits,  bottles  or  bladders  of  hot 
water,  heated  bricks,  etc.,  to  the  limbs  and  soles  of  the  feet. 

Rule  IV. — After  treatment. — Externally:  As  soon  as  breathing  is 
established  let  the  patient  be  stripped  of  all  wet  clothing,  wrapped 
in  blankets  only,  put  to  bed  comfortably  warm,  but  with  a  free 
circulation  of  fresh  air,  and  left  to  perfect  rest.  Internally:  Give 


86  . 

whisky  or  brandy  and  hot  water  in  doses  of  a  teaspoonful  to  a 
tablespoonful,  according  to  the  weight  of  the  patient,  or  other  stimu- 
lant at  hand,  every  ten  or  fifteen  minutes  for  the  first  hour,  and  as 
often  thereafter  as  may  seem  expedient.  Later  manifestations: 
After  reaction  is  fully  established  there  is  great  danger  of  congestion 
of  the  lungs,  and  if  perfect  rest  is  not  maintained  for  at  least  forty- 
eight  hours,  it  sometimes  occurs  that  the  patient  is  seized  with  great 
difficulty  of  breathing,  and  death  is  liable  to  follow  unless  immediate 
relief  is  afforded.  In  such  cases  apply  a  large  mustard  plaster  over 
the  breast.  If  the  patient  gasps  for  breath  before  the  mustard  takes 
effect,  assist  the  breathing  by  carefully  repeating  the  artificial  respi- 
ration. 

MODIFICATION  OP  RULE  III. 

[To  be  used  after  Rules  I  and  II  in  case  no  assistance  is  at  hand.] 

To  produce  respiration. — If  no  assistance  is  at  hand  and  one  person 
must  work  alone,  place  the  patient  on  his  back  with  the  shoulders 


FIG.  30. 

slightly  raised  on  a  folded  article  of  clothing;  draw  forward  the 
tongue  and  keep  it  projecting  just  beyond  the  lips:  if  the  lower  jaw 
be  lifted  the  teeth  may  be  made  to  hold  the  tongue  in  place ;  it  may 
be  necessary  to  retain  the  tongue  by  passing  a  handkerchief  under 
the  chin  and  tying  it  over  the  head. 

Grasp  the  arms  just  below  the  elbows  and  draw  them  steadily 
upward  by  the  sides  of  the  patient's  head  to  the  ground,  the  hands 
nearly  meeting.  (See  fig.  30.) 


87 

Xext  lower  the  arms  to  the  side  and  press  firmly  downward  and 
inward  on  the  sides  and  front  of  the  chest  over  the  lower  ribs, 
drawing  toward  the  patient's  head.  (See  fig.  31.) 

Repeat  these  movements  twelve  to  fifteen  times  every  minute,  etc. 

INSTRUCTIONS   FOR   SAVING   DROWNING   PERSONS   BY   SWIMMING  TO   THEIR 

RELIEF. 

1.  When  you  approach  a  person  drowning  in  the  water,  assure  him, 
with  a  loud  and  firm  voice,  that  he  is  safe. 

2.  Before  jumping  in  to  save  him,  divest  yourself  as  far  and  as 
quickly  as  possible  of  all  clothes;   tear  them  off,  if  necessary;   but  if 
there  is  not  time,  loose  at  all  events  the  foot  of  your  drawers,  if  they 
are  tied,  as,  if  you  do  not  do  so,  they  fill  with  water  and  drag  you. 

3.  On  swimming  to  a  person  in  the  sea,  if  he  be  struggling  do  not 
seize  him  then,  but  keep  off  for  a  few  seconds  till  he  gets  quiet,  for  it 


FIG.  31. 

is  sheer  madness  to  take  hold  of  a  man  when  he  is  struggling  in  the 
water,  and  if  you  do  you  run  a  great  risk. 

4.  Then  get  close  to  him  and  take  fast  hold  of  the  hair  of  his  head, 
turn  him  as  quickly  as  possible  onto  his  back,  give  him  a  sudden 
pull,  and  this  will  cause  him  to  float,  then  throw  yourself  on  your 
back  also  and  swim  for  the  shore,  both  hands  having  hold  of  his 
hair,  you  on  your  back,  and  he  also  on  his,  and  of  course  his  back  to 
your  stomach.  In  this  way  yon  will  get  sooner  and  safer  ashore  than 
by  any  other  means,  and  you  can  easily  thus  swim  with  two  or  three 
persons;  the  writer  has  even,  as  an  experiment,  done  it  with  four, 
and  gone  with  them  40  or  50  yards  in  the  sea.  One  great  a'dvantage 


88 

of  this  method  is  that  it  enables  you  to  keep  your  head  up  and  also 
to  hold  the  person's  head  up  you  are  trying  to  save.  It  is  of  primary 
importance  that  you  take  fast  hold  of  the  hair  and  throw  both  the 
person  and  yourself  on  your  backs.  After  many  experiments,  it  is 
usually  found  preferable  to  all  other  methods.  You  can  in  this  man- 
ner float  nearly  as  long  as  you  please,  or  until  a  boat  or  other  help 
can  be  obtained. 

5.  It  is  believed  there  is  no  such  thing  as  a  death  grasp;   at  least 
it  is  very  unusual  to  witness  it.     As  soon  as  a  drowning  man  begins 
to  get  feeble  and  to  lose  his  recollection,  he  gradually  slackens  his 
hold  until  he  quits  it  altogether.     No  apprehension  need,  therefore, 
be  felt  on  that  head  when  attempting  to  rescue  a  drowning  person. 

6.  After  a  person  has  sunk  to  the  bottom,  if  the  water  be  smooth, 
the  exact  position  where  the  body  lies  may  be  known  by  the  air 
bubbles,  which  will  occasionally  rise  to  the  surface,  allowance  being 
of  course  made  for  the  motion  of  the  wrater,  if  in  a  tide  way  or 
stream,  wrhich  will  have  carried  the  bubbles  out  of  a  perpendicular 
course  in  rising  to  the  surface.     Oftentimes  a  body  may  be  regained 
from  the  bottom,  before  too  late  for  recovery,  by  diving  for  it  in 
the  direction  indicated  by  these  bubbles. 

7.  On  rescuing  a  person  by  diving  to  the  bottom,  the  hair  of  the 
head  should  be  seized  by  one  hand  only,  and  the  other  used  in  con- 
junction with  the  feet  in  raising  yourself  and  the  drowning  person 
to  the  surface. 

8.  If  in  the  sea,  it  may  sometimes  be  a  great  error  to  try  to  get 
to  land.     If  there  be  a  strong  "  outsetting  "  tide,  and  }'Ou  are  swim- 
ming either  by  yourself  or  having  hold  of  a  person  who  can  not 
swim,  then  get  on  your  back  and  float  till  help  comes.     Many  a 
man  exhausts  himself  by  stemming  the  billows  for  the  shore  on  a 
back-going  tide,  and  sinks  in  the  effort,  when,  if  he  had  floated,  a 
boat  or  other  aid  might  have  been  obtained. 

9.  These  instructions  apply  alike  to  all  circumstances,  whether  as 
regards  the  roughest  sea  or  smooth  water. 


APPENDIX. 


THE  UNITED  STATES  PUBLIC  HEALTH  AND  MARINE-HOSPITAL 

SERVICE. 


The  United  States  Marine-Hospital  Service  was  established  by  an  act  of  Con- 
gress approved  July  16,  1798.  By  this  act  Congress  imposed  a  tax  of  20  cents 
a  month  on  every  seaman  employed  on  vessels  of  the  United  States  engaged  in 
the  foreign  or  coasting  trades,  and  out  of  the  money  collected  by  authority  of 
this  act  the  President  of  the  United  States  was  authorized  to  furnish  tempo- 
rary relief  to  sick  and  disabled  seamen.  The  said  act  was  amended  March  2, 
1799,  extending  the  operations  of  the  law  so  as  to  include  the  officers  and  sea- 
men of  the  Navy ;  but  in  the  year  1811  separate  hospitals  were  established  for 
the  Navy. 

Under  an  act  of  Congress  approved  June  29,  1870,  the  hospital  tax  was  in- 
creased from  20  to  40  cents  a  month,  at  which  rate  it  was  continued  until 
1884,  when,  by  an  act  of  Congress,  the  hospital  tax  was  abolished  and  the  ton- 
nage tax  was  made  available  for  the  ordinary  expenses  of  the  Service  (for  the 
care  and  treatment  of  sick  and  disabled  American  seamen). 

By  act  of  Congress  approved  July  1,  1902,  the  name  of  the  Service  was 
changed  to  that  of  the  Public  Health  and  Marine-Hospital  Service  of  the 
United  States. 

The  medical  corps  of  the  Public  Health  and  Marine-Hospital  Service  consists 
of  the  Surgeon-General,  surgeons,  passed  assistant  surgeons,  acting  assistant 
surgeons,  and  sanitary  inspectors. 

The  Surgeon-General  is  the  head  of  the  Service.  He  is  required  by  law, 
under  the  direction  of  the  Secretary  of  the  Treasury,  to  supervise  all  matters 
connected  with  the  Public  Health  and  Marine-Hospital  Service,  including  the 
National  Quarantine  Service  and  the  medical  work  in  connection  with  the 
Immigration  Service. 

RELIEF  STATIONS,  BENEFICIARIES,  ETC. 

[Extracts  from  the  Regulations,  Public  Health  and  Marine-Hospital  Service,  1903.] 

BELIEF    STATIONS. 

PAR.  404.  A  relief  station  of  the  Public  Health  and  Marine-Hospital  Service 
is  a  port  or  place  where  an  officer  of  the  Service  is  on  duty  to  extend  relief  to 
seamen  or  where  an  officer  of  the  customs  service  is  specifically  authorized 
to  extend  said  relief. 

PAR.  405.  Relief  stations  shall  be  divided  into  the  following  classes : 

Class  I. — United  States  marine  hospitals. 

Class  II. — All  other  stations  under  command  of  a  commissioned  officer. 

Class  III. — All  stations  under  charge  of  an  acting  assistant  surgeon  where 
there  is  a  contract  for  the  care  of  sick  and  disabled  seamen. 

Class  IV. — All  other  relief  stations  not  included  in  the  above  classes. 

89 


90 

BENEFICIARIES. 

PAR.  411.  The  persons  entitled  to  the  benefits  of  the  Public  Health  and 
Marine-Hospital  Service  are  those  employed  on  board  in  the  care,  preservation, 
or  navigation  of  any  registered,  enrolled,  or  licensed  vessels  of  the  United 
States,  or  in  the  Service  on  board  of  those  engaged  in  such  care,  preservation, 
or  navigation.  Officers  and  crews  of  the  Light-House  Establishment,  officers 
and  crews  of  the  Revenue-Cutter  Service,  seamen  employed  on  the  vessels  of 
the  Mississippi  River  Commission,  seamen  employed  on  the  vessels  of  the  Engi- 
neer Corps  of  the  Army,  and  keepers  and  crews  of  the  United  States  Life- 
Saving  Service  are  entitled  to  the  facilities  of  the  hospitals  and  relief  stations 
under  special  rules  hereinafter  prescribed. 

PAR.  412.  Officers  on  vessels  of  the  Coast  and  Geodetic  Survey,  and  seamen 
thereon,  who  are  not  enlisted  men  from  the  Navy,  are  entitled  to  the  benefits  of 
the  Service. 

PAR.  413.  Seamen  employed  on  yachts  are  entitled  to  treatment,  provided  the 
said  yachts  are  enrolled,  licensed,  or  registered  as  vessels  of  the  United  States. 

PAR.  414.  Seamen  employed  on  United  States  army  transports  or  other  ves- 
sels belonging  to  the  Quartermaster's  Department,  United  States  Army,  when 
not  enlisted  men  of  the  Army,  are  entitled  to  the  benefits  of  the  Service. 

PAR.  415.  No  person  employed  in  or  connected  with  the  navigation,  manage- 
ment, or  use  of  canal  boats  engaged  in  the  coasting  trade  shall,  by  reason 
thereof,  be  entitled  to  any  benefit  or  relief  from  the  Service. 

PAB.  417.  Seamen  taken  from  wrecked  vessels  of  the  United  States  are  entitled 
to  the  benefits  of  the  Service  if  sick  or  disabled,  and  will  be  furnished  care  and 
treatment  without  reference  to  the  length  of  time  they  have  been  employed. 

PAR.  418.  Seamen  employed  on  merchant  vessels  of  the  United  States  returned 
to  the  United  States  from  foreign  ports  by  United  States  consular  officers, 
if  sick  or  disabled  at  the  time  of  their  arrival  in  a  port  of  the  United  States, 
shall  be  entitled  to  the  benefits  of  the  Service  without  reference  to  length  of 
service. 

PAB.  419.  A  sick  or  disabled  seaman,  in  order  to  obtain  the  benefits  of  the 
Service,  must  apply  in  person,  or  by  proxy  if  too  sick  or  disabled  so  to  do,  at 
the  office  of  the  Public  Health  and  Marine-Hospital  Service,  to  an  officer  of  that 
Service,  or  to  the  proper  customs  officer  acting  as  the  agent  of  the  said  Service 
at  stations  where  no  medical  officer  is  on  duty,  and  must  furnish  satisfactory 
evidence  that  he  is  entitled  to  relief  under  the  regulations. 

PAR.  420.  Masters'  certificates  and  discharges  from  United  States  shipping 
commissioners,  made  out  and  signed  in  proper  form,  showing  that  the  applicant 
for  relief  has  been  employed  for  sixty  days  of  continuous  service  "  in  a  regis- 
tered, enrolled,  or  licensed  vessel  of  the  United  States,"  a  part  of  which  must 
have  been  during  the  sixty  days  immediately  preceding  his  application  for  relief, 
shall  entitle  him  to  treatment.  The  phrase  "  sixty  days'  continuous  service " 
shall  not  be  held  to  exclude  seamen  whose  papers  show  brief  intermission 
between  short  services  that  aggregate  the  required  sixty  days. 

PAR.  440.  Seamen  taken  sick  or  injured  while  actually  employed  on  a  doc- 
umented vessel  shall  be  entitled  to  treatment  at  relief  stations  without  reference 
to  the  length  of  their  service. 

PAR.  421.  The  certificate  of  the  owner  or  accredited  commercial  agent  of  a  ves- 
sel as  to  the  facts  of  the  employment  of  any  seaman  on  said  vessel  may  be 
accepted  as  evidence  in  lieu  of  the  master's  certificate  in  cases  where  the 
latter  is  not  procurable. 

PAR.  422.  Masters  of  documented  vessels  of  the  United  States  shall,  on 
demand,  furnish  any  seaman  who  has  been  employed  on  such  vessel  a  certifi- 


91 

cate  (Form  1915)  of  the  length  of  time  said  seaman  has  been  so  employed, 
giving  the  dates  of  such  employment.  This  certificate  will  be  filed  in  the  marine- 
hospital  office  or  office  of  the  customs  officer  when  application  is  made  for  relief, 
whether  the  relief  is  furnished  or  the  claim  rejected. 

PAR.  423.  Any  master  of  a  vessel  or  other  person  who  shall  furnish  a  false 
certificate  of  service,  with  intent  to  procure  the  admission  of  a  seaman  into 
any  marine  hospital,  shall  be  immediately  reported  to  the  nearest  United 
States  attorney  for  prosecution. 

PAB.  424.  When  an  interval  has  occurred  in  the  applicant's  seafaring  service 
by  reason  of  the  closure  of  navigation  on  account  of  ice  or  low  water,  such  inter- 
val shall  not  be  considered  as  excluding  him  from  relief  unless  the  sickness  or 
injury  for  which  he  applies  for  relief  be  the  direct  result  of  employment  on 
shore. 

HOSPITAL  BELIEF. 

PAB.  480.  A  sick  or  disabled  seaman  entitled  to  the  benefits  of  the  Service 
shall  be  admitted  to  hospital  only  in  cases  where  the  gravity  of  the  disease 
or  injury  from  which  he  suffers  is  such  as  to  require  hospital  treatment  in 
the  opinion  of  an  officer  of  the  Service,  or  of  a  reputable  physician  designated  by 
the  Department  to  act  at  a  place  where  no  officer  is  stationed. 

PAB.  442.  Temporary  relief  only  is  contemplated,  and  admission  to  hospital 
is  not  intended  to  permit  an  indefinite  residence  therein  for  cause  other  than 
actual  disease  or  injury. 

PAB.  482.  Officers  shall  not  be  required  to  attend  sick  or  disabled  seamen 
on  board  vessels  or  to  visit  them  in  harbor,  except  at  the  discretion  of  the 
officer  to  whom  the  application  is  made. 

OUT-PATIENT    BELIEF. 

PAB.  467.  Sick  and  disabled  seamen  entitled  under  these  regulations  to  the  ben- 
efits of  the  Service  whose  diseases  or  injuries  are  of  such  a  nature  that  they 
can  properly  be  relieved  by  medicines,  dressings,  or  advice,  without  admission 
to  hospital,  shall  be  treated  as  out-patients,  and  furnished  medicines,  dressings, 
surgical  appliances,  or  advice,  as  the  case  may  require. 

PAB.  434.  When  a  seaman  who  has  received  continuous  treatment  at  the  out- 
patient office  for  a  period  of  two  months  applies  for  further  treatment,  he  must, 
to  entitle  him  to  treatment,  furnish  a  new  cerificate  of  service,  showing  that 
he  is  still  following  his  vocation  as  seaman,  or  give  satisfactory  evidence  that 
such  service  has  been  prevented  by  closure  of  navigation  or  by  sickness,  the 
latest  dates  of  service,  and,  in  case  of  lack  of  recent  service,  its  explanation,  to 
appear  in  each  new  relief  certificate. 

THE   BEVENUE-CUTTEB    SEBVICE. 

PAB.  444.  The  officers  and  crews  of  the  Revenue-Cutter  Service  will  receive 
hospital  or  out-patient  treatment,  as  hereinafter  provided,  on  certificate  signed 
by  the  commanding  officer  or  executive  officer  of  a  revenue  cutter  without  regard 
to  length  of  service.  The  certificate  shall  contain  a  description  of  the  applicant 
for  relief.  Officers  on  leave  or  waiting  orders  may  sign  their  own  certificate. 

PAB.  449.  At  ports  where  there  is  a  marine  hospital  station,  when  an  officer 
or  member  of  a  crew  of  the  Revenue-Cutter  Service,  on  account  of  injury  or 
illness,  requires  the  immediate  attention  of  a  physician,  and  on  account  of  the 
exigency  of  the  case  it  is  impossible  to  convey  the  patient  to  the  marine  hos- 
pital or  office,  temporary  provision  for  medical  attendance  or  care  may  be  made 
by  the  commanding  officer,  who  will  immediately  report  his  action  to  the  proper 
marine-hospital  representative  at  the  port,  and  the  treatment  thereafter  will 


92 

be  conducted  by  tfle  Public  Health  and  Marine- Hospital  Service  in  the  manner 
provided  in  the  annual  circular  entitled  "  Contracts  for  care  of  seamen,  etc.," 
if  in  the  judgment  of  the  proper  officer  of  the  Public  Health  and  Marine-Hospital 
Service  it  can  be  done  without  detriment  to  the  patient.  *  *  * 

PAE.  450.  Commissioned  medical  officers  and  acting  assistant  surgeons  of  the 
Public  -Health  and  Marine-Hospital  Service  will  render  professional  aid  to  offi- 
cers of  the  Revenue-Cutter  Service  residing  at  the  port  at  their  residences  when 
said  officers  of  the  Revenue-Cutter  Service  for  any  reason  can  not  avail  them- 
selves of  the  accommodations  offered  by  the  marine  hospital  and  when  they  are 
physically  unable  to  present  themselves  at  the  marine-hospital  office.  The  med- 
icines or  appliances  prescribed  shall  be  furnished  from  the  dispensary  of  the 
Public  Health  and  Marine-Hospital  Service  when  practicable. 

THE    MISSISSIPPI   RIVER    COMMISSION. 

PAR.  452.  Masters,  officers,  and  crews,  of  vessels  in  the  service  of  the  Missis- 
sippi River  Commission  shall  be  entitled  to  the  benefits  of  the  Marine-Hospital 
Service  (except  at  stations  of  the  fourth  class)  under  the  same  regulations  as 
govern  the  admission  of  seamen  on  documented  vessels.  *  *  * 

THE   ENGINEER    CORPS,    UNITED    STATES    ARMY. 

PAR.  453.  Seamen  employed  on  vessels  under  the  charge  of  the  Engineer  Corps 
of  the  United  States  Army  shall  be  admitted  to  the  benefits  of  the  Marine-Hos- 
pital Service  without  charge  at  stations  of  the  first,  second,  and  third  class  upon 
the  written  request  of  the  commanding  officers  of  said  vessels. 

THE   LIFE-SAVING    SERVICE. 

PAR.  454.  Keepers  and  surfmen  of  the  Life-Saving  Service  will  be  treated  in 
the  marine  hospitals,  but  not  at  their  homes,  and  will  receive  out-patient  relief 
only  at  the  dispensaries  connected  with  the  Service.  Keepers  and  surfmen  will 
be  entitled  to  the  ordinary  accommodations  of  the  hospitals,  and  will  comply 
with  all  rules  and  regulations  relating  to  discipline  and  management. 

PAR.  455.  An  applicant  must  present  a  certificate  signed  by  a  keeper,  district 
superintendent,  or  assistant  inspector  of  the  Life-Saving  Service,  in  the  form 
prescribed  by  the  Department,  testifying  to  his  services  as  keeper  or  surfman  of 
a  life-saving  station,  and  giving  other  satisfactory  evidence  that  he  is  entitled  to 
treatment.  When  it  is  impracticable  to  obtain  the  certificate,  signed  as  above 
required,  an  affidavit  of  the  applicant  as  to  the  facts  of  his  employment  may  be 
accepted.  The  applicant  must  be  required  to  sign  his  name  to  the  certificate 
before  it  is  signed  by  the  officer  issuing  it. 

PAR.  456.  The  certificate  must  show  that  the  applicant  is  borne  upon  the  rolls 
of  the  Life-Saving  Service  at  the  time  of  making  the  application.  Applicants 
who  have  been  discharged  from  the  Life-Saving  Service,  being  no  longer  mem- 
bers thereof,  are  not  entitled  to  treatment. 

PAR.  457.  During  the  period  when  the  life-saving  stations  are  open  sick  or 
injured  keepers  or  surfmen  will  be  admitted  to  hospital  or  out-patient  treatment 
according  to  the  necessities  of  the  case. 

PAR.  458.  During  the  months  when  the  stations  are  closed  sick  or  injured 
keepers  or  surfmen  will  be  admitted  as  above,  unless  the  sickness  or  injury 
is  the  result  of  employment  not  connected  with  the  United  States  Life-Saving 
Service.  If  injured  or  taken  sick  during  said  months  as  a  result  of  employment 
not  connected  with  the  Life-Saving  Service,  treatment  will  not  be  granted. 

PAR.  459.  Under  the  terms  of  the  act  of  August  4,  1894,  a  marine  hospital  will 
not  be  considered  a  home  for  sick  or  disabled  keepers  or  surfmen  of  the  Life- 


93 

Saving  Service.  .  Temporary  treatment  alone  is  permitted,  and  no  keeper  or 
surfman  will  be  retained  in  hospital  longer  than  ninety  days  unless  special 
authorization  is  given  by  the  Bureau. 

THE   LIGHT-HOUSE    SERVICE. 

PAR.  460.  Officers  and  crews  of  the  several  vessels  belonging  to  the  Light- 
House  Establishment,  including  light-ships,  may  be  admitted  to  the  benefits  of 
the  Public  Health  and  Marine-Hospital  Service  upon  the  application  of  their 
respective  commanding  officers. 

UNITED    STATES    ARMY    AND    NAVY. 

PAR.  461.  Officers  and  enlisted  men  of  the  United  States  Army  and  Navy  may 
be  admitted  for  care  and  treatment  as  patients  of  the  Service  only  upon  the 
written  request  of  their  respective  commanding  officers.  Every  such  admission 
shall  be  immediately  reported  to  the  Surgeon-General  by  the  officer  in  charge 
of  the  station,  on  a  daily  report  (Form  1957)  or  relief  certificate  (Form  1916), 
accompanied  by  a  copy  of  the  request  upon  which  such  officer  or  enlisted  man 
was  admitted.  They  shall  be  furnished  treatment  at  stations  of  the  first,  sec- 
ond, and  third  class  only.  The  rate  of  charge  to  be  made  for  the  care  and 
treatment  of  the  said  officers  and  enlisted  men  will  be  fixed  by  the  Department 
at  the  beginning  of  each  fiscal  year. 

FOREIGN    SEAMEN. 

•  ' 

PAR.  462.  The  accommodations  provided  for  the  care  and  treatment  of  the 
patients  of  the  Public  Health  and  Marine-Hospital  Service  are  also  available 
to  foreign  seamen  at  relief  stations  of  the  first,  second,  and  third  class  upon 
the  application  of  the  consular  officer  of  the  nation  under  whose  flag  they  are 
sailing  or  upon  the  application  of  the  masters  of  the  vessels  upon  which  said 
seamen  serve,  provided  satisfactory  written  security  is  given  for  the*  payment 
of  the  expenses  of  such  care  and  treatment,  at  rates  fixed  annually  by  the 
Department.  *  *  * 


INDEX. 


Page. 

Acute  rheumatism  (rheumatic  fever)  .                                       42 

Alcoholic  liquors 9 

Ankle,  dislocation  of - 78 

Apparently  drowned: 

To  expel  water  from  stomach  and  chest  of,  illustration  (fig.  27) 83 

To  produce  breathing  in,  illustration  (figs.  28,  29) . .  .  84-85 

To  produce  respiration  in,  illustration  (figs.  30,  31 ) 86-87 

Appendix: 

Beneficiaries 90 

Engineer  Corps,  United  States  Army 92 

Foreign  seamen . . . 93 

Hospital  relief 91 

Life-Saving  Service  . . 92 

Light-House  Service 93 

Mississippi  River  Commission 92 

Out-patient  relief .  91 

Relief  stations 89 

Revenue-Cutter  Service 91 

United  States  Army  and  Navy 93 

Arm,  fracture  of  (between  elbow  and  shoulder) . .  63 

Splints  and  bandages  for  treatment  of,  illustrations  (figs. 7,  8,9) 63-64 

Treatment  of .       .63 

Articles,  miscellaneous 7 

Asiatic  cholera 24 

Back,  injuries  of 59 

Treatment  of 59 

Bandage  for  treatment  of  ulcer,  illustration  (fig.  26) 81 

Bandages  and  splints  for  treatment  of  fracture  of: 

Arm,  illustrations  (figs.  7,8,9) .... 63-64 

Kneecap,  illustration  (fig.  14) 69 

Lower  jaw,  illustrations  (figs.  3,  4,  5,  6) 61 

Beriberi . .  29 

Bleeding 53 

Boils . 52 

Treatment  of 53 

Box,  fracture,  for  treatment  of  fracture  of  leg,  illustration  (fig.  20) 72 

Broken  bones . 59 

Burns  or  scalds ... 56 

Treatment  of 56 

Capsules 8 

95 


96 

Page. 
Catheter: 

Curve  of  channel  through  which  must  pass,  illustration  (fig.  2) 51 

How  to  use,  illustration  (fig.  1) 5 1 

Chancre,  soft ; _ . .        46 

Chest  and  stomach,  to  expel  water  from,  illustration  (fig.  27)  _.  83 

Chest,  injuries  of .     58 

Treatment  of 59 

Cholera  (epidemic  cholera,  Asiatic  cholera)  _  24 

Treatment  of 26 

Cliolera  morbus  (cholera  nostras,  sporadic  cholera) . .  36 

Treatment  of  . .  36 

Chronic  rheumatism . .  42 

Clap  (gonorrhea) 48 

Colic 37 

Treatment  of  .......  37 

Collar  bone,  dislocation  of  .  78 

Treatment  of  _  -  78 

Compound  fractures  - .  72 

Treatment  of 73 

Delirium  tremens 44 

Treatment  of 45 

Diarrhea .  35 

Treatment  of 35 

Directions  for  restoring  the  apparently  drowned .  _  82 

Dislocations  .  _  73 

Ankle,  treatment  of 78 

Collar  bone 78 

Treatment  of  . .  78 

Elbow..  75 

Treatment  of  . .  76 

Fingers. ,__.  74 

Treatment  of  .  _ . 75 

Hip 79 

Illustration  (figs.  24, 25) ....  ....        80 

Treatment  of  . .  80 

Knee 79 

Treatment  of  . .  79 

Shoulder 77 

Illustration  (fig.  23)..  76 

Treatment  of  .  77 

Symptoms  and  signs  of  .  77 

Thumb..  74 

Illustration  (fig.  21 ) 75 

Treatment  of 74 

Toes 78 

Treatment  of  ...  78 

Wrist -  75 

Treatment  of  _  75 

Double  inclined  plane  for  treatment  of  fracture  of  thigh,  illustrations 

(figs.  10,  11) 66 

Drowned,  directions  for  restoring  the  apparently  _ . 

Drowning  persons,  instructions  for  saving,  by  swimming  to  their  relief  _. 

Drugs  and  medicines . . , 


97 

Page. 

Dysentery 32 

Symptoms  of 32 

Treatment  of __ 33 

Tropical..  32 

Effects  of  cold,  frostbite 57 

Treatment  of  . . .  57 

Elbow,  dislocation  of 75 

Treatment  of 76 

Elixirs,  tinctures,  essences,  etc 9 

Epidemic  cholera 24 

Erysipelas  (St.  Anthony's  Fire) . .  - 40 

Treatment  of 41 

Essences,  elixirs,  tinctures,  etc 9 

Face,  wounds  of 58 

Treatment  of 58 

Fever,  malarial 16 

Treatment  of  . .  19 

Fever: 

Pernicious  malarial 18 

Rheumatic  (acute  rheumatism) 42 

Treatment  of  .-  42 

Yellow _ 11 

Fingers,  dislocation  of 74 

Treatment  of- _.  75 

Fingers  and  thumb: 

Fracture  of 62 

Treatment  of  _ 62 

Forearm,  fracture  of _  62 

Treatment  of 63 

Fracture: 

Arm  (between  elbow  and  shoulder) 63 

Treatment  of  . .  63 

Arm  splints  and  bandages  for  treatment  of,  illustrations  (figs.  7, 8,  9)  _  _  63-64 

Forearm _ 62 

Treatment  of 63 

Kneecap _ _  _  69 

Symptoms  and  signs  of : '  69 

Treatment  of _ 69 

Leg  (between  knee  and  ankle) _ 70 

Treatment  of 71 

Leg,  fracture  box  for  treatment  of,  illustration  (fig.  20) 72 

Lower  jaw 60 

Splints  and  bandages  for  treatment  of,  illustrations  (figs.  3,  4,  5,  6)  _  61 

Treatment  of . . .  61 

Fracture,  Pott's: 

Appearance  of  right  foot  after,  illustration  (fig.  17) 71 

Application  of  splint  for,  illustration  (fig.  19) 71 

As  shown  on  the  skeleton .  illustration  (fig.  18) 71 

Fracture  of  thigh 65 

Double  inclined  plane  for  treatment  of,  illustrations  (figs.  10, 11) 66 

Long  splint  for  treatment  of,  illustration  (fig.  13) 67 

13256—04  M 7 


98 

Fracture  of  thigh — Continued.  Page. 

Short  splints  for  treatment  of,  illustration  (fig.  14) _ 67 

Treatment  of  _ .                                               65 

Weight  and  pulley  for  treatment  of,  illustration  (fig.  12) 67 

Fracture  of  thumb  and  fingers 62 

Treatment  of 62 

Fracture  box,  for  treatment  of  fracture  of  leg.  illustration  (fig.  20) 72 

Fractures,  compound 72 

Treatment  of 73 

Frostbite,  treatment  of 57 

Gonorrhea  (clap) 48 

Treatment  of 49 

Gonorrheal  rheumatism 43 

Hemorrhage 53 

Hip,  dislocation  of 79 

Illustrations  (figs.  24,  25) 80 

Treatment  of 80 

Illustrations: 

Appearance  of  right  foot  after  a  Pott's  fracture  (fig.  17) 71 

Application  of  splint  for  Pott's  fracture  (fig.  19) 71 

Application  of  weight  and  pulley  in  treatment  of  fracture  of  thigh 

(fig.  15) -  68 

Bandage  for  treatment  of  ulcer  (fig.  26) 81 

Catheter,  how  to  use  (fig.  1) ._. 51 

Curve  of  channel  through  which  catheter  must  pass  (fig.  2) 51 

Dislocation  of  shoulder  (fig.  23) ..  76 

Dislocation  of  the  hip  (figs.  24,  25) ..  80 

Dislocation  of  thumb  and  method  of  replacing  (figs.  21 , 22)  _  _ _  75 

Double  inclined  plane  for  treatment  of  fracture  of  the  thigh  ( figs  .10,11).  66 

Fracture  box  for  treatment  of  fracture  of  leg  (fig.  20)  _ .  72 

Long  splints  for  treatment  of  fracture  of  the  thigh  (fig.  13) . 67 

Pott's  fracture  as  shown  on  the  skeleton  (fig.  18) 71 

Respiration  in  the  apparently  drowned  (figs.  30,  31) _  _  86-87 

Short  splints  for  treatment  of  fracture  of  the  thigh  (fig.  14) 67 

Splint  and  bandage  for  treatment  or  fracture  of  kneecap  (fig.  16) 69 

Splints  and  bandages  for  treatment  of  fracture  of  arms  (figs.  7,  8,  9)..  63-64 
Splints  and  bandages  for  treatment  of  fracture  of  lower  jaw  (figs.  3,  4, 

5,6) 61 

To  expel  water  from  stomach  and  chest  (fig.  27) 83 

To  produce  breathing  in  the  apparently  drowned  (figs.  28,  29) . . 84-85 

Weight  and  pulley  for  treatment  of  fracture  of  the  thigh  (fig.  12) 67 

Injuries  of: 

Chest 58 

Treatment  of  . . 59 

Back 59 

Treatment  of  . .  59 

Instructions  for  saving  drowning  persons  by  swimming  to  their  relief 87 

Instruments,  surgical . 7 

Itch  (scabies) \ 52 

Treatment  of 52 

Jaw,  lower,  fracture  of 60 

Splints  and  bandages  for  treatment  of,  illustrations  (figs.  3,  4,  5,  6) 61 

1      Treatment  of  _ .  61 


99 

Page! 

Knee,  dislocation  of . . .  79 

Treatment  of 79 

Kneecap,  fracture  of « . .  69 

Symptoms  and  signs  of 69 

Treatment  of 69 

Leg,  fracture  of  (between  knee  and  ankle) 70 

Treatment  of  . :•_ 71 

Liquors,  alcoholic 9 

Lower  jaw,  fracture  of 60 

Splints  and  bandages  for  treatment  of,  illustrations  (figs.  3,  4,  5,  6) .  _  61 

Treatment  of 61 

Lozenges 8 

Malarial  fever  _ .  16 

Pernicious 18 

Treatment  of 19 

Medicines  and  drugs 8 

Miscellaneous  articles 7 

Muscular  rheumatism  .  42 

Nosebleed 81 

Treatment  of  ...  82 

Pills  ....  8 

Plague 26 

Pott's  fracture: 

Appearance  of  right  foot  after,  illustration  (fig.  17) 71 

As  shown  on  the  skeleton,  illustration  (fig.  18) 71 

Application  of  splint  for,  illustration  (fig.  19) . .  71 

Pernicious  malarial  fever 18 

Treatment  of  . .  19 

Piles  ..  53 

Treatment  of  ...  53 

Quinsy  (sore  throat) 39 

Restoration  of  the  apparently  drowned,  directions  for .  . ..  82 

Rheumatic  fever  (acute  rheumatism) 42 

Treatment  of 42 

Rheumatism: 

Acute  (rheumatic  fever) 42 

Treatment  of  . .  42 

Chronic 42 

Treatment  of .  _  43 

Gonorrheal 43 

Treatment  of 44 

Muscular _ 42 

Treatment  of 43 

Syphilitic-.  44 

Treatment  of 44 

St.  Anthony's  fire  (erysipelas) 40 

Scabies  (itch) 52 

Scalds  or  burns 56 

Treatment  of 56 

Scalp,  wounds  of —  58 

Treatment  of -  -  -  58 

Scurvey ...  38 

Symptoms  of 38 

Treatment  of  . .  39 


100 

•  Page. 

Shoulder,  dislocation  of 77 

Illustration  (fig.  23) 76 

Treatment  of.. 72 

Smallpox 21 

Treatment  of 23 

Soft  chancre 46 

Treatment  of r 47 

Sore  throat  (tonsilitis,  quinsy) 39 

Treatment  of 40 

Splints : 

For  Pott's  fracture,  application  of,  illustration  (fig.  19) 71 

Long,  for  treatment  of  fracture  of  thigh,  illustration  (fig.  13) 67 

Short,  for  treatment  of  fracture  of  thigh,  illustration  (fig.  14) 67 

Splints  and  bandages  for  treatment  of  fracture  of  lower  jaw,  illustrations 

(figs.  3,4.5,6) 61 

Splints  and  bandages  for  treatment  of  fracture  of  arm,  illustrations  (figs. 

7,8,9) .  63-64 

Splints  and  bandages  for  treatment  of  fracture  of  kneecap,  illustration 

(fig.  16) : 69 

Sprains 81 

Treatment  of . 81 

Stomach  and  chest,  to  expel  water  from,  illustration  (fig.  27) 83 

Stoner ,  George  W. ,  surgeon 3 

Stricture  of  urethra 50 

Directions  for  passing  catheter,  illustrations  (figs.  1,2) _  51 

Treatment  of ;... 51 

Surgical  instruments 7 

Sunstroke 34 

Treatment  of  _ .  34 

Syphilis  . .  45 

Treatment  of _ 46 

Syphilitic  rheumatism 44 

Tablets 8 

Tablet  triturates. 8 

The  apparently  drowned,  directions  for  restoring _ 82 

The  plague 26 

Thigh,  fracture  of _ 65 

Double  inclined  plane  for  treatment  of,  illustrations  (figs.  10,  11) 66 

Long  splint  for  treatment  of,  illustration  (fig.  13)  -  _  67 

Short  splints  for  treatment  of,  illustration  (fig.  14)  _. 67 

Treatment  of 65 

Weight  and  pulley  for  treatment  of,  illustration  (fig.  12) 67 

Thumb  and  fingers,  fracture  of „___ •_.  62 

Treatment  of  . . .  03 

Thumb,  dislocation  of 74 

Illustration  (fig.  21 ) 75 

Treatment  of 75 

Tinctures,  elixirs,  essences,  etc 9 

Toes,  dislocation  of * 78 

Treatment  of : 78 

Tonsilitis  (sore  throat) '__ 39 

Tropical  dysentery 

Ulcer,  bandage  for  treatment  of,  illustration  (fig.  26) 81 


101 

Page. 

Urethra,  stricture  of 50 

Weight  and  pulley : 

Application  of,  in  treatment  of  fracture  of  thigh,  illustration  (fig.  15).  68 

For  treatment  of  fracture  of  thigh,  illustration  ( fig.  12) 67 

Wounds  of  face 58 

Treatment  of  . .  58 

Wounds  of  scalp 58 

Treatment  of 58 

Wounds  and  injuries : 53-54 

Wrist,  dislocation  of .  75 

Treatment  of 75 

Wyman,  Walter,  Surgeon-General  - 57 

Yellow  fever 11 

Treatment  of  . .  14 


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